2023 HCPCS LEVEL II, PROFESSIONAL EDITION ISBN: 978-1-64016-228-0

Copyright © 2023 by Elsevier Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopying, recording, or any information storage and
retrieval system, without permission in writing from the publisher. Details on how to seek
permission, further information about the Publisher’s permissions policies and our
arrangements with organizations such as the Copyright Clearance Center and the Copyright
Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by
the Publisher (other than as may be noted herein).

Notice

Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds or experiments described
herein. Because of rapid advances in the medical sciences, in particular, independent
verification of diagnoses and drug dosages should be made. To the fullest extent of the
law, no responsibility is assumed by Elsevier, authors, editors or contributors for any
injury and/or damage to persons or property as a matter of products liability, negligence or
otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.

Previous editions copyrighted 2022, 2021, 2020, 2019, 2018, 2017, 2016, 2015, 2014, 2013,
2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2003, 2002, 2001, 2000
International Standard Book Number: 978-1-64016-228-0

Our Commitment to Accuracy

The American Medical Association (AMA) is committed to producing accurate and reliable
materials. To report corrections, please call the AMA Unified Service Center at (800) 621-
8335. The AMA publication and product updates, errata, and addenda can be found at ama-
assn.org/product-updates. The AMA shall not be responsible for, and expressly disclaims
liability for, damages of any kind arising out of the use of, reference to, or reliance on, the
content of this publication. This publication is for informational purposes only.

To purchase additional copies, contact the AMA at 800-621-8335 or visit the AMA store at
amastore.com. Refer to item number OP231523.

Content Strategist: Laura Klein

Content Development Manager: Danielle Frazier
Senior Content Development Specialist: Joshua S. Rapplean
Publishing Services Manager: Deepthi Unni
Project Manager: Aparna Venkatachalam
Senior Book Designer: Maggie Reid

Printed in Canada

Last digit is the print number: 9 8 7 6 5 4 3 2 1

 DEVELOPMENT OF THIS EDITION

Lead Technical Collaborator

Jackie L. Koesterman, CPC
Coding and Reimbursement Specialist
JDK Medical Coding EDU
Grand Forks, North Dakota
 CONTENTS

INTRODUCTION

GUIDE TO USING THE 2023 HCPCS LEVEL II CODES

SYMBOLS AND CONVENTIONS

2023 HCPCS UPDATES

ANATOMY ILLUSTRATIONS

2023 HCPCS INDEX

2023 TABLE OF DRUGS

2023 HCPCS LEVEL II MODIFIERS

2023 HCPCS LEVEL II NATIONAL CODES

Appendix A—Jurisdiction List for DMEPOS HCPCS Codes

Appendix B—General Correct Coding Policies: National

Correct Coding Initiative Policy Manual for Medicaid Services

Figure Credits
Updates will be posted on codingupdates.com when available.

Check codingupdates.com for Practitioner and Facility Medically Unlikely Edits

(MUEs) and Column 1 and Column 2 Edits.

Check the Centers for Medicare & Medicaid Services

(www.cms.gov/Manuals/IOM/list.asp) website and codingupdates.com for full
and select IOMs.

Notice: 2023 DMEPOS updates were unavailable at the time of printing. Check
codingupdates.com for updates and DMEPOS Modifiers in January.
 INTRODUCTION

2023 HCPCS quarterly updates available on the companion

website at: www.codingupdates.com
The Centers for Medicare & Medicaid Services (CMS) (formerly Health Care
Financing Administration [HCFA]) Healthcare Common Procedure Coding
System (HCPCS) is a collection of codes and descriptors that represent
procedures, supplies, products, and services that may be provided to Medicare
beneficiaries and to individuals enrolled in private health insurance programs.
The codes are divided as follows:
Level I: Codes and descriptors copyrighted by the American Medical
Association’s (AMA’s) Current Procedural Terminology, ed. 4 (CPT-4). These
are five-digit numeric codes representing physician and nonphysician services.
Level II: Includes codes and descriptors copyrighted by the American Dental
Association’s current dental terminology, seventh edition (CDT-7/8). These are
five-digit alphanumeric codes comprising the D series. All other Level II
codes and descriptors are alphanumeric and approved and maintained jointly
by the editorial panel (consisting of CMS, the Health Insurance Association of
America, and the Blue Cross Blue Shield Association). These are five-digit
alphanumeric codes representing primarily items and nonphysician services
that are not represented in the Level I codes.
Level III: The CMS eliminated Level III local codes. See Program
Memorandum AB-02-113.
Headings are provided as a means of grouping similar or closely related items.
The placement of a code under a heading does not indicate additional means of
classification, nor does it relate to any health insurance coverage categories.
HCPCS also contains modifiers, which are two-digit codes and descriptors
used to indicate that a service or procedure that has been performed has been
altered by some specific circumstance but unchanged in its definition or code.
Modifiers are grouped by levels. Level I modifiers and descriptors are
copyrighted by the AMA. Level II modifiers are HCPCS modifiers. Modifiers in
the D series are copyrighted by the ADA.
HCPCS is designed to promote uniform reporting and statistical data
collection of medical procedures, supplies, products, and services.

HCPCS Disclaimer
Inclusion or exclusion of a procedure, supply, product, or service does not imply
any health insurance coverage or reimbursement policy.
HCPCS makes as much use as possible of generic descriptions, but the
inclusion of brand names to describe devices or drugs is intended only for
indexing purposes; it is not meant to convey endorsement of any particular
product or drug.

Updating HCPCS
The primary updates are made annually. Quarterly updates are also issued by
CMS.
 GUIDE TO USING THE 2023 HCPCS
LEVEL II CODES

Medical coding has long been a part of the health care profession. Through the
years medical coding systems have become more complex and extensive. Today,
medical coding is an intricate and immense process that is present in every health
care setting. The increased use of electronic submissions for health care services
only increases the need for coders who understand the coding process.
2023 HCPCS Level II was developed to help meet the needs of today’s coder.
All material adheres to the latest government versions available at the time of
printing.

Annotated
Throughout this text, revisions and additions are indicated by the following
symbols:
▶ New: Additions to the previous edition are indicated by the color
triangle.
Revised: Revisions within the line or code from the previous
edition are indicated by the color arrow.
✔ Reinstated indicates a code that was previously deleted and has
now been reactivated.
✖ Deleted words have been removed from this year’s edition.

HCPCS Symbols
❂ Special coverage instructions apply to these codes. Usually these
special coverage instructions are included in the Internet Only
Manuals (IOM). References to the IOM locations are given in the
form of Medicare Pub. 100 reference numbers listed below the
 code. IOM select references are located at codingupdates.com.
Not covered or valid by Medicare is indicated by the “No”
symbol. Usually the reason for the exclusion is included in the
Internet Only Manuals (IOM) select references at
codingupdates.com.
✽ Carrier discretion is an indication that you must contact the
individual third-party payers to find out the coverage available for
codes identified by this symbol.
Other Drugs approved for Medicare Part B and other FDA-approved
drugs are listed as Other.
A2-Z3 ASC Payment Indicators identify the 2019 final payment for the
code. A list of Payment Indicators is listed in the front matter of
this text.
A-Y OPPS Status Indicators identify the 2019 final status assigned to
the code. A list of Status Indicators is listed in the front matter of
this text.
Bill Part B MAC.
Bill DME MAC.
Coding Clinic Indicates the American Hospital Association Coding Clinic® for
HCPCS references by year, quarter, and page number.
DMEPOS identifies durable medical equipment, prosthetics,
orthotics, and supplies that may be eligible for payment from CMS.
♀ Indicates a code for female only.
♂ Indicates a code for male only.
Indicates a code with an indication of age.
Indicates a code included in the MIPS Quality Measure
Specifications.
Indicates there is a maximum allowable number of units of service,
per day, per patient for physician/provider services (see
codingupdates.com for Practitioner Medically Unlikely Edits).
Indicates there is a maximum allowable number of units of service,
per day, per patient in the outpatient hospital setting (see
codingupdates.com for Hospital Medically Unlikely Edits).
Red, green, and blue typeface terms within the Table of Drugs and
tabular section are terms added by the publisher and do not appear
in the official code set. Information supplementing the official
HCPCS Index produced by CMS is italicized.
SYMBOLS AND CONVENTIONS
Codes shown are for illustration purposes only and may not be current codes.

A2-Z3 ASC Payment Indicators

Final ASC Payment Indicators for CY 2023
Payment Payment Indicator Definition
Indicator
A2 Surgical procedure on ASC list in CY 2007; payment based on
OPPS relative payment weight.
B5 Alternative code may be available; no payment made.
D5 Deleted/discontinued code; no payment made.
F4 Corneal tissue acquisition, hepatitis B vaccine; paid at reasonable
cost.
G2 Non-office-based surgical procedure added in CY 2008 or later;
payment based on OPPS relative payment weight.
H2 Brachytherapy source paid separately when provided integral to a
surgical procedure on ASC list; payment OPPS rate.
J7 OPPS pass-through device paid separately when provided
integral to a surgical procedure on ASC list; payment contractor-
priced.
J8 Device-intensive procedure; paid at adjusted rate.
K2 Drugs and biologicals paid separately when provided integral to a
surgical procedure on ASC list; payment based on OPPS rate.
K5 Drugs and biologicals for which pricing information is not yet
available.
K7 Unclassified drugs and biologicals; payment contractor-priced.
L1 Influenza vaccine; pneumococcal vaccine. Packaged item/service;
no separate payment made.
L6 New Technology Intraocular Lens (NTIOL); special payment.
N1 Packaged service/item; no separate payment made.
P2 Office-based surgical procedure added to ASC list in CY 2008 or
later with MPFS nonfacility PE RVUs; payment based on OPPS
relative payment weight.
P3 Office-based surgical procedure added to ASC list in CY 2008 or
later with MPFS nonfacility PE RVUs; payment based on MPFS
nonfacility PE RVUs.
R2 Office-based surgical procedure added to ASC list in CY 2008 or
later without MPFS nonfacility PE RVUs; payment based on
OPPS relative payment weight.
Z2 Radiology or diagnostic service paid separately when provided
integral to a surgical procedure on ASC list; payment based on
OPPS relative payment weight.
 Z3 Radiology or diagnostic service paid separately when provided
integral to a surgical procedure on ASC list; payment based on
MPFS nonfacility PE RVUs.
CMS-1772-FC, Final Changes to the ASC Payment System and CY 2023 Payment Rates,
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/ASC-Regulations-and-
Notices.html.

A-Y OPPS Status Indicators

Final OPPS Payment Status Indicators for CY 2023
Indicator Item/Code/Service OPPS Payment Status
A Services furnished to a hospital Not paid under OPPS. Paid by
outpatient that are paid under a MACs under a fee schedule or
fee schedule or payment system payment system other than OPPS.
other than OPPS,* for example: Services are subject to deductible
or coinsurance unless indicated
otherwise.
• Ambulance Services
• Separately Payable Clinical Not subject to deductible or
Diagnostic Laboratory Services coinsurance.
• Separately Payable Non-
Implantable Prosthetics and
Orthotics
• Physical, Occupational, and
Speech Therapy
• Diagnostic Mammography
• Screening Mammography Not subject to deductible or
coinsurance.
B Codes that are not recognized by Not paid under OPPS.
OPPS when submitted on an
outpatient hospital Part B bill type • May be paid by MACs when
(12x and 13x) submitted on a different bill
type, for example, 75x (CORF),
but not paid under OPPS.
• An alternate code that is
recognized by OPPS when
submitted on an outpatient
hospital Part B bill type (12x
and 13x) may be available.
C Inpatient Procedures Not paid under OPPS. Admit
patient. Bill as inpatient.
D Discontinued Codes Not paid under OPPS or any other
Medicare payment system.
E1 Items, Codes and Services: Not paid by Medicare when
• Not covered by any Medicare submitted on outpatient claims
outpatient benefit category (any outpatient bill type).
• Statutorily excluded by
Medicare
• Not reasonable and necessary
E2 Items, Codes and Services: Not paid by Medicare when
for which pricing information and submitted on outpatient claims
claims data are not available (any outpatient bill type).
F Corneal Tissue Acquisition; Not paid under OPPS. Paid at
Certain CRNA Services and reasonable cost.
Hepatitis B Vaccines
G Pass-Through Drugs and Paid under OPPS; separate APC
Biologicals payment.
H Pass-Through Device Categories Separate cost-based pass-through
payment; not subject to
copayment.
J1 Hospital Part B services paid Paid under OPPS; all covered Part
through a comprehensive APC B services on the claim are
packaged with the primary “J1”
service for the claim, except
services with OPPS status
indicator of “F,” “G,” “H,” “L,”
and “U”; ambulance services;
diagnostic and screening
mammography; all preventive
services; and certain Part B
inpatient services.
J2 Hospital Part B Services That Paid under OPPS; Addendum B
May Be Paid Through a displays APC assignments when
Comprehensive APC services are separately payable.
(1) Comprehensive APC
payment based on OPPS
 comprehensive-specific
payment criteria. Payment for
all covered Part B services on
the claim is packaged into a
single payment for specific
combinations of services,
except services with OPPS
status indicator of “F,” “G,”
“H,” “L,” and “U”;
ambulance services;
diagnostic and screening
mammography; all preventive
services; and certain Part B
inpatient services.
(2) Packaged APC payment if
billed on the same claim as a
HCPCS code assigned status
indicator “J1.”
(3) In other circumstances,
payment is made through a
separate APC payment or
packaged into payment for
other services.
K Non-Pass-Through Drugs and Paid under OPPS: separate APC
Non-Implantable Biologicals, payment.
including Therapeutic
Radiopharmaceuticals
L Influenza Vaccine; Pneumococcal Not paid under OPPS. Paid at
Pneumonia Vaccine reasonable cost; not subject to
deductible or coinsurance.
M Items and Services Not Billable to Not paid under OPPS.
the MAC
N Items and Services Packaged into Paid under OPPS; payment is
APC Rates packaged into payment for other
services. Therefore, there is no
separate APC payment.
P Partial Hospitalization Paid under OPPS; per diem APC
payment.
Q1 STV-Packaged Codes Paid under OPPS; Addendum B
 displays APC assignments when
services are separately payable.
(1) Packaged APC payment if
billed on the same claim as a
HCPCS code assigned status
indicator “S,” “T,” or “V.”
(2) Composite APC payment if
billed with specific
combinations of services
based on OPPS composite-
specific payment criteria.
Payment is packaged into a
single payment for specific
combinations of services.
(3) In other circumstances,
payment is made through a
separate APC payment.
Q2 T-Packaged Codes Paid under OPPS; Addendum B
displays APC assignments when
services are separately payable.
(1) Packaged APC payment if
billed on the same claim as a
HCPCS code assigned status
indicator “T.”
(2) In other circumstances,
payment is made through a
separate APC payment.

Q3 Codes That May Be Paid Through Paid under OPPS; Addendum B

a Composite APC displays APC assignments when
services are separately payable.
Addendum M displays composite
APC assignments when codes are
paid through a composite APC.
(1) Composite APC payment
based on OPPS composite-
specific payment criteria.
Payment is packaged into a
single payment for specific
 combinations of service.
(2) In other circumstances,
payment is made through a
separate APC payment or
packaged into payment for
other services.
Q4 Conditionally packaged Paid under OPPS or CLFS.
laboratory tests
(1) Packaged APC payment if
billed on the same claim as a
HCPCS code assigned
published status indicator
“J1,” “J2,” “S,” “T,” “V,”
“Q1,” “Q2,” or “Q3.”
(2) In other circumstances,
laboratory tests should have
an SI=A and payment is made
under the CLFS.

R Blood and Blood Products Paid under OPPS; separate APC

payment.
S Procedure or Service, Not Paid under OPPS; separate APC
Discounted when Multiple payment.
T Procedure or Service, Multiple Paid under OPPS; separate APC
Procedure Reduction Applies payment.
U Brachytherapy Sources Paid under OPPS; separate APC
payment.
V Clinic or Emergency Department Paid under OPPS; separate APC
Visit payment.
Y Non-Implantable Durable Not paid under OPPS. All
Medical Equipment institutional providers other than
home health agencies bill to a
DME MAC.
* Note — Payments “under a fee schedule or payment system other than OPPS” may be contractor priced.
CMS-1772-FC, Final Changes to the ASC Payment System and CY 2023 Payment Rates,
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-
Regulations-and-Notices.html.
 2023 HCPCS
UPDATES

2023 HCPCS New/Revised/Deleted Codes

and Modifiers
HCPCS quarterly updates are posted on the companion website
(www.codingupdates.com) when available.

NEW CODES/MODIFIERS
AB
JZ
LU
A4239
C1747
C1826
C1827
C7500
C7501
C7502
C7503
C7504
C7505
C7506
C7507
C7508
C7509
C7510
C7511
C7512
C7513
C7514
C7515
C7516
C7517
C7518
C7519
C7520
C7521
C7522
C7523
C7524
C7525
C7526
C7527
C7528
C7529
C7530
C7531
C7532
C7533
C7534
C7535
C7537
C7538
C7539
C7540
C7541
C7542
C7543
C7544
C7545
C7546
C7547
C7548
C7549
C7550
C7551
C7552
C7553
C7554
C7555
C7900
C7901
C7902
C9143
C9144
E2103
G0316
G0317
G0318
G0320
G0321
G0322
G0323
G0330
G3002
G3003
J0134
J0136
J0173
J0225
J0283
J0611
J0689
J0701
J0703
J0877
J0891
J0892
J0893
J0898
J0899
J1456
J1574
J1611
J1643
J2021
J2184
J2247
J2251
J2272
J2281
J2311
J2327
J2401
J2402
J3244
J3371
J3372
J9046
J9048
J9049
J9393
J9394
M0001
M0002
M0003
M0004
M0005
M1150
M1151
M1152
M1153
M1154
M1155
M1156
M1157
M1158
M1159
M1160
M1161
M1162
M1163
M1164
M1165
M1166
M1167
M1168
M1169
M1170
M1171
M1172
M1173
M1174
M1175
M1176
M1177
M1178
M1179
M1180
M1181
M1182
M1183
M1184
M1185
M1186
M1187
M1188
M1189
M1190
M1191
M1192
M1193
M1194
M1195
M1196
M1197
M1198
M1199
M1200
M1201
M1202
M1203
M1204
M1205
M1206
M1207
M1208
M1209
M1210
Q4262
Q4263
Q4264
Q5126

REVISED CODES/MODIFIERS
JG
TB
A4238
A9276
A9277
A9278
C1831
C9761
E2102
G0029
G0030
G0442
G0444
G0917
G2136
G2137
G2138
G2139
G2140
G2141
G2146
G2147
G2152
G2167
G2174
G2182
G2199
G2202
G2204
G2207
G2210
G2212
G4013
G4020
G8451
G8539
G8543
G8600
G8601
G8602
G8633
G8647
G8648
G8650
G8651
G8652
G8654
G8655
G8656
G8658
G8659
G8660
G8662
G8663
G8664
G8666
G8667
G8668
G8670
G8694
G8708
G8710
G8711
G8734
G8826
G8842
G8843
G8844
G8852
G8854
G8923
G8934
G8942
G8968
G9315
G9404
G9407
G9418
G9500
G9501
G9624
G9626
G9662
G9663
G9781
G9789
G9847
G9848
G9905
G9906
G9908
G9913
G9943
G9946
G9949
G9968
G9969
G9970
G9990
G9991
G9993
J0131
J0610
J9041
M1003
M1052
 DELETED CODES/MODIFIERS
C1841
C1842
C1849
C9142
G0028
G0308
G0309
G2095
G2170
G2171
G2198
G2201
G2203
G9196
G9197
G9198
G9250
G9251
G9359
G9360
G9506
G9618
G9620
G9623
G9631
G9632
G9633
G9718
G9774
G9778
G9808
G9809
G9810
G9811
G9904
G9907
G9909
G9932
G9942
G9948
G9989
J2400
J9044
K0553
K0554
M1017
M1071
 NEW, REVISED, AND DELETED DENTAL CODES
New
D0372
D0373
D0374
D0387
D0388
D0389
D0801
D0802
D0803
D0804
D1781
D1782
D1783
D4286
D6105
D6106
D6107
D6197
D7509
D7956
D7957
D9953
Revised
D0210
D0709
D0393
D3333
D4240
D4241
D4355
D4921
D7251
D9450

Deleted
D0351
D0704
Plate 1 Cranial Nerves (12 pairs) are known by their numbers (Roman numerals) and names.
(Herlihy BL: The Human Body in Health and Illness, ed 6, St. Louis, 2018, Elsevier.)
Plate 2 Nerves of Orbit. (Copyright 2022 Elsevier Inc. All rights reserved.
www.netterimages.com. Image ID: 4615.)
Plate 3 Innervation of the Hand: Median and Ulnar Nerves (From Drake RL, Vogl AW,
Mitchell AWM, Tibbitts RM, Richardson PE: Gray’s Atlas of Anatomy, ed 2, Philadelphia,
2015, Churchill Livingstone.)
Plate 4 Arteries and Nerves of the Forearm (Anterior View) (From Drake RL, Vogl AW,
Mitchell AWM, Tibbitts RM, Richardson PE: Gray’s Atlas of Anatomy, ed 2, Philadelphia,
2015, Churchill Livingstone.)
Plate 5 Superficial Nerves and Veins of Lower Limb: Anterior View. (Copyright 2022
Elsevier Inc. All rights reserved. www.netterimages.com. Image ID: 4846.)
Plate 6 Superficial Nerves and Veins of Lower Limb: Posterior View. (Copyright 2022
Elsevier Inc. All rights reserved. www.netterimages.com. Image ID: 4669.)
Plate 7 Arteries and Nerves of Thigh: Anterior Views. (Copyright 2022 Elsevier Inc. All
rights reserved. www.netterimages.com. Image ID: 4475.)
Plate 8 Arteries and Nerves of Thigh: Posterior View. (Copyright 2022 Elsevier Inc. All
rights reserved. www.netterimages.com. Image ID: 49316.)
Plate 9 Arteries and Nerves of Thigh: Posterior View. (Copyright 2022 Elsevier Inc. All
rights reserved. www.netterimages.com. Image ID: 49317.)
Plate 10 Anatomy of the Eye. (Dehn RW, Asprey DP: Essential Clinical Procedures, ed 3,
Philadelphia, 2013, Saunders.)
Plate 11 Intrinsic Arteries and Veins of Eye. (Copyright 2022 Elsevier Inc. All rights
reserved. www.netterimages.com. Image ID: 49107.)
Plate 12 Anatomy of the Conjunctiva and Eyelids. (Kumar V, Abbas AK, Aster JC: Robbins
and Cotran Pathologic Basis of Disease, ed 9, Philadelphia, 2015, Saunders.)

Plate 13 Eyelid. (Copyright 2022 Elsevier Inc. All rights reserved. www.netterimages.com.
Image ID: 4557.)
Plate 14 Lacrimal Apparatus. (Copyright 2022 Elsevier Inc. All rights reserved.
www.netterimages.com. Image ID: 49103.)
Plate 15 Pathway of Sound. (LaFleur Brooks D, LaFleur Brooks M: Basic Medical
Language, ed 4, St. Louis, 2013, Mosby.)

Plate 16 Middle Ear Structures. (©Elsevier Collection.)

Plate 17 Structural Landmarks of Tympanic Membrane. (Ignatavicius DD, Workman ML:
Medical-Surgical Nursing: Patient-Centered Collaborative Care, ed 7, St. Louis, 2013,
Saunders.)

Plate 18 Inner Ear Structures. (©Elsevier Collection.)

Plate 19 The Tooth. (©Elsevier Collection).

Plate 20 Adult Teeth. (©Elsevier Collection).

Plate 21 A, Dorsal view of tongue showing the roughened large lingual tonsils on the
posterior of the tongue and the foliate papillae on the side. B, Section of dorsal of the tongue
showing a cutaway through lingual papillae and showing von Ebner’s glands at the base of
the vallate papilla. (Brand RW, Isselhard DE: Anatomy of Orofacial Structures: A
Comprehensive Approach, ed 8, St. Louis, 2019, Elsevier.)

Plate 22 Paranasal Sinuses. (Copyright 2022 Elsevier Inc. All rights reserved.
www.netterimages.com. Image ID: 8427.)
Plate 23 Salivary Glands. (Copyright 2022 Elsevier Inc. All rights reserved.
www.netterimages.com. Image ID: 4396.)
Plate 24 Coronary Arteries: Arteriographic Views. (Copyright 2022 Elsevier Inc. All rights
reserved. www.netterimages.com. Image ID: 4725.)
Plate 25 Coronary Arteries: Arteriographic Views. (Copyright 2022 Elsevier Inc. All rights
reserved. www.netterimages.com. Image ID: 4542.)
Plate 26 Arteries of Brain: Frontal View and Section. (Copyright 2022 Elsevier Inc. All
rights reserved. www.netterimages.com. Image ID: 4588.)
Plate 27 Mucosa and Musculature of Large Intestine. (Copyright 2022 Elsevier Inc. All
rights reserved. www.netterimages.com. Image ID: 4778.)
Plate 28 Cross Section of Thorax at T3-4 Disc Level. (Copyright 2022 Elsevier Inc. All
rights reserved. www.netterimages.com. Image ID: 4880.)
Plate 29 Knee joint opened; anterior, posterior, and proximal views. A, Anterior view of the
knee joint, opened by folding the patella and patellar ligament inferiorly. On the lateral side is
the fibular collateral ligament, separated by the popliteal tendon from the lateral meniscus.
On the medial side, the tibial collateral ligament is attached to the medial meniscus. The
anterior and posterior cruciate ligaments are seen between the femoral condyles. B, Posterior
view of the opened knee joint with a more complete view of the posterior cruciate ligament.
C, The femur is removed, showing the proximal (articular) end of the right tibia. On the
medial side is the gently curved medial meniscus; on the lateral side is the more tightly
curved lateral meniscus. The anterior end of the medial meniscus is anchored to the surface
of the tibia by the transverse ligament. The cut ends of the anterior and posterior cruciate
ligaments are shown, as well as the meniscofemoral ligament. (Fritz S: Mosby’s Essential
Sciences for Therapeutic Massage: Anatomy, Physiology, Biomechanics, and Pathology, ed
5, St. Louis, 2017, Elsevier.)
INDEX
 A
Abatacept, J0129
Abciximab, J0130
Abdomen
dressing holder/binder, A4461, A4463
pad, low profile, L1270
Abduction control, each, L2624
Abduction restrainer, A4566
Abduction rotation bar, foot, L3140–L3170
adjustable shoe style positioning device, L3160
including shoes, L3140
plastic, heel-stabilizer, off-shelf, L3170
without shoes, L3150
Abecma, Q2055
AbobotulinumtoxinA, J0586
Absorption dressing, A2001–A2010, A2015–A2018, A6251–A6256 ◀
Access, site, occlusive, device, G0269
Access system, A4301
Accessories
ambulation devices, E0153–E0159
crutch attachment, walker, E0157
forearm crutch, platform attachment, E0153
leg extension, walker, E0158
replacement, brake attachment, walker, E0159
seat attachment, walker, E0156
walker, platform attachment, E0154
wheel attachment, walker, per pair, E0155
artificial kidney and machine; (see also ESRD), E1510–E1699
adjustable chair, ESRD patients, E1570
automatic peritoneal dialysis system, intermittent, E1592
bath conductivity meter, hemodialysis, E1550
blood leak detector, hemodialysis, replacement, E1560
blood pump, hemodialysis, replacement, E1620
cycler dialysis machine, peritoneal, E1594
deionizer water system, hemodialysis, E1615
delivery/installation charges, hemodialysis equipment, E1600
hemodialysis machine, E1590
hemostats, E1637
 heparin infusion pump, hemodialysis, E1520
kidney machine, dialysate delivery system, E1510
peritoneal dialysis clamps, E1634
portable travel hemodialyzer, E1635
reciprocating peritoneal dialysis system, E1630
replacement, air bubble detector, hemodialysis, E1530
replacement, pressure alarm, hemodialysis, E1540
reverse osmosis water system, hemodialysis, E1610
scale, E1639
sorbent cartridges, hemodialysis, E1636
transducer protectors, E1575
unipuncture control system, E1580
water softening system, hemodialysis, E1625
wearable artificial kidney, E1632
beds, E0271–E0280, E0300–E0326
bed board, E0273
bed, board/table, E0315
bed cradle, E0280
bed pan, standard, E0275
bed side rails, E0305–E0310
bed-pan fracture, E0276
hospital bed, extra heavy duty, E0302, E0304
hospital bed, heavy duty, E0301–E0303
hospital bed, pediatric, electric, E0329
hospital bed, safety enclosure frame, E0316
mattress, foam rubber, E0272
mattress, innerspring, E0271
over-bed table, E0274
pediatric crib, E0300
powered pressure-reducing air mattress, E0277
wheelchairs, E0950–E1030, E1050–E1298, E2300–E2399, K0001–K0109
accessory tray, E0950
arm rest, E0994
back upholstery replacement, E0982
calf rest/pad, E0995
commode seat, E0968
detachable armrest, E0973
elevating leg rest, E0990
headrest cushion, E0955
lateral trunk/hip support, E0956
loop-holder, E0951–E0952
 manual swingaway, E1028
manual wheelchair, adapter, amputee, E0959
manual wheelchair, anti-rollback device, E0974
manual wheelchair, anti-tipping device, E0971
manual wheelchair, hand rim with projections, E0967
manual wheelchair, headrest extension, E0966
manual wheelchair, lever-activated, wheel drive, E0988
manual wheelchair, one-arm drive attachment, E0958
manual wheelchair, power add-on, E0983–E0984
manual wheelchair, push activated power assist, E0986
manual wheelchair, solid seat insert, E0992
medial thigh support, E0957
modification, pediatric size, E1011
narrowing device, E0969
No. 2 footplates, E0970
oxygen related accessories, E1352–E1406
positioning belt/safety belt/pelvic strap, E0978
power-seating system, E1002–E1010
reclining back addition, pediatric size wheelchair, E1014
residual limb support system, E1020
safety vest, E0980
seat lift mechanism, E0985
seat upholstery replacement, E0981
shock absorber, E1015–E1018
shoulder harness strap, E0960
ventilator tray, E1029–E1030
wheel lock brake extension, manual, E0961
wheelchair, amputee, accessories, E1170–E1200
wheelchair, fully inclining, accessories, E1050–E1093
wheelchair, heavy duty, accessories, E1280–E1298
wheelchair, lightweight, accessories, E1240–E1270
wheelchair, semi-reclining, accessories, E1100–E1110
wheelchair, special size, E1220–E1239
wheelchair, standard, accessories, E1130–E1161
whirlpool equipment, E1300–E1310
Ace type, elastic bandage, A6448–A6450
Acetaminophen, J0131, J0134, J0136 ◀
Acetazolamide sodium, J1120
Acetylcysteine
inhalation solution, J7604, J7608
injection, J0132
Activity, therapy, G0176
Acyclovir, J0133
Adalimumab, J0135
Additions to
fracture orthosis, L2180–L2192
abduction bar, L2300–L2310
adjustable motion knee joint, L2186
anterior swing band, L2335
BK socket, PTB and AFO, L2350
disk or dial lock, knee flexion, L2425
dorsiflexion and plantar flexion, L2220
dorsiflexion assist, L2210
drop lock, L2405
drop lock knee joint, L2182
extended steel shank, L2360
foot plate, stirrup attachment, L2250
hip joint, pelvic band, thigh flange, pelvic belt, L2192
integrated release mechanism, L2515
lacer custom-fabricated, L2320–L2330
lift loop, drop lock ring, L2492
limited ankle motion, L2200
limited motion knee joint, L2184
long tongue stirrup, L2265
lower extremity orthrosis, L2200–L2397
molded inner boot, L2280
offset knee joint, L2390
offset knee joint, heavy duty, L2395
Patten bottom, L2370
pelvic and thoracic control, L2570–L2680
plastic shoe insert with ankle joints, L2180
polycentric knee joint, L2387
pre-tibial shell, L2340
quadrilateral, L2188
ratchet lock knee extension, L2430
reinforced solid stirrup, L2260
rocker bottom, custom fabricated, L2232
round caliper/plate attachment, L2240
split flat caliper stirrups, L2230
straight knee joint, heavy duty, L2385
straight knee, or offset knee joints, L2405–L2492
suspension sleeve, L2397
 thigh/weight bearing, L2500–L2550
torsion control, ankle joint, L2375
torsion control, straight knee joint, L2380
varus/valgus correction, L2270–L2275
waist belt, L2190
general additions, orthosis, L2750–L2999
lower extremity, above knee section, soft interface, L2830
lower extremity, concentric adjustable torsion style mechanism, L2861
lower extremity, drop lock retainer, L2785
lower extremity, extension, per extension, per bar, L2760
lower extremity, femoral length sock, L2850
lower extremity, full kneecap, L2795
lower extremity, high strength, lightweight material, hybrid lamination, L2755
lower extremity, knee control, condylar pad, L2810
lower extremity, knee control, knee cap, medial or lateral, L2800
lower extremity orthrosis, non-corrosive finish, per bar, L2780
lower extremity orthrosis, NOS, L2999
lower extremity, plating chrome or nickel, per bar, L2750
lower extremity, soft interface, below knee, L2820
lower extremity, tibial length sock, L2840
orthotic side bar, disconnect device, L2768
Adenosine, J0151, J0153
Adhesive, A4364
bandage, A6413
disc or foam pad, A5126
remover, A4455, A4456
support, breast prosthesis, A4280
wound, closure, G0168
Adjunctive, dental, D9110–D9999
Administration, chemotherapy, Q0083–Q0085
both infusion and other technique, Q0085
infusion technique only, Q0084
other than infusion technique, Q0083
Administration, Part D
vaccine, hepatitis B, G0010
vaccine, influenza, G0008
vaccine, pneumococcal, G0009
Administrative, Miscellaneous and Investigational, A9000–A9999
alert or alarm device, A9280
artificial saliva, A9155
DME delivery set-up, A9901
 exercise equipment, A9300
external ambulatory insulin delivery system, A9274
foot pressure off loading/supportive device, A9283
helmets, A8000–A8004
home glucose disposable monitor, A9275
hot-water bottle, ice cap, heat wrap, A9273
miscellaneous DME, NOS, A9999
miscellaneous DME supply, A9900
monitoring feature/device, stand-alone or integrated, A9279
multiple vitamins, oral, per dose, A9153
non-covered item, A9270
non-prescription drugs, A9150
pediculosis treatment, topical, A9180
radiopharmaceuticals, A9500–A9700
reaching grabbing device, A9281
receiver, external, interstitial glucose monitoring system, A9278
sensor, invasive, interstitial continuous glucose monitoring, A9276
single vitamin/mineral trace element, A9152
spirometer, non-electronic, A9284
transmitter, interstitial continuous glucose monitoring system, A9277
wig, any type, A9282
wound suction, disposable, A9272
Admission, observation, G0379
Ado-trastuzumab, J9354
Adrenalin, J0171
Aducanumab-avwa, J0172 ◀
Aduhelm, J0172
Advanced life support, A0390, A0426, A0427, A0433
ALS2, A0433
ALS emergency transport, A0427
ALS mileage, A0390
ALS, non-emergency transport, A0426
Aerosol
compressor, E0571–E0572
compressor filter, A7013–A7014, K0178–K0179
mask, A7015, K0180
Afamelanotide implant, J7352
Aflibercept, J0178
AFO, E1815, E1830, L1900–L1990, L4392, L4396
Afstyla, J7210
Agalsidase beta, J0180
Aggrastat, J3245
A-hydroCort, J1710
Aid, hearing, V5030–V5263
Aide, home, health, G0156, S9122, T1021
home health aide/certified nurse assistant, in home, S9122
home health aide/certified nurse assistant, per visit, T1021
home health or hospital setting, G0156
Air bubble detector, dialysis, E1530
Air fluidized bed, E0194
Air pressure pad/mattress, E0186, E0197
Air travel and nonemergency transportation, A0140
Alarm
not otherwise classified, A9280
pressure, dialysis, E1540
Alatrofloxacin mesylate, J0200
Albumin, human, P9041, P9042
Albuterol
all formulations, inhalation solution, J7620
all formulations, inhalation solution, concentrated, J7610, J7611
all formulations, inhalation solution, unit dose, J7609, J7613
Alcohol, A4244
Alcohol wipes, A4245
Alcohol/substance, assessment, G0396, G0397, H0001, H0003, H0049
alcohol abuse structured assessment, greater than 30 min., G0397
alcohol abuse structured assessment, 15–30 min., G0396
alcohol and/or drug assessment, Medicaid, H0001
alcohol and/or drug screening; laboratory analysis, Medicaid, H0003
alcohol and/or drug screening, Medicaid, H0049
Aldesleukin (IL2), J9015
Alefacept, J0215
Alemtuzumab, J0202
Alert device, A9280
Alginate dressing, A6196–A6199
alginate, pad more than 48 sq. cm, A6198
alginate, pad size 16 sq. cm, A6196
alginate, pad size more than 16 sq. cm, A6197
alginate, wound filler, sterile, A6199
Alglucerase, J0205
Alglucosidase, J0220
Alglucosidase alfa, J0221
Allogen, Q4212
Alphanate, J7186
Alpha-1–proteinase inhibitor, human, J0256, J0257
Alprostadil
injection, J0270
urethral suppository, J0275
ALS mileage, A0390
Alteplase recombinant, J2997
Alternating pressure mattress/pad, A4640, E0180, E0181, E0277
overlay/pad, alternating, pump, heavy duty, E0181
powered pressure-reducing air mattress, E0277
replacement pad, owned by patient, A4640
Alveoloplasty, D7310–D7321
in conjunction with extractions, four or more teeth, D7310
in conjunction with extractions, one to three teeth, D7311
not in conjunction with extractions, four or more teeth, D7320
not in conjunction with extractions, one to three teeth, D7321
Alymsys, Q5126 ◀
Amalgam dental restoration, D2140–D2161
four or more surfaces, primary or permanent, D2161
one surface, primary or permanent, D2140
three surfaces, primary or permanent, D2160
two surfaces, primary or permanent, D2150
Ambulance, A0021–A0999
air, A0430, A0431, A0435, A0436
conventional, transport, one way, fixed wing, A0430
conventional, transport, one way, rotary wing, A0431
fixed wing air mileage, A0435
rotary wing air mileage, A0436
disposable supplies, A0382–A0398
ALS routine disposable supplies, A0398
ALS specialized service disposable supplies, A0394
ALS specialized service, esophageal intubation, A0396
BLS routine disposable, A0832
BLS specialized service disposable supplies, defibrillation, A0384, A0392
non-emergency transport, fixed wing, S9960
non-emergency transport, rotary wing, S9961
oxygen, A0422
Ambulation device, E0100–E0159
brake attachment, wheeled walker replacement, E0159
cane, adjustable or fixed, with tip, E0100
cane, quad or three prong, adjustable or fixed, with tip, E0105
 crutch attachment, walker, E0157
crutch forearm, each, with tips and handgrips, E0111
crutch substitute, lower leg platform, with or without wheels, each, E0118
crutch, underarm, articulating, spring assisted, each, E0117
crutches forearm, pair, tips and handgrips, E0110
crutches, underarm, other than wood, pair, with pads, tips and handgrips, E0114
crutches, underarm, other than wood, with pad, tip, handgrip, with or without shock
absorber, each, E0116
crutches, underarm, wood, each, with pad, tip and handgrip, E0113
leg extensions, walker, set (4), E0158
platform attachment, forearm crutch, each, E0153
platform attachment, walker, E0154
seat attachment, walker, E0156
walker, enclosed, four-sided frame, wheeled, posterior seat, E0144
walker, folding, adjustable or fixed height, E0135
walker, folding, wheeled, adjustable or fixed height, E0143
walker, heavy duty, multiple braking system, variable wheel resistance, E0147
walker, heavy duty, wheeled, rigid or folding, E0149
walker, heavy duty, without wheels, rigid or folding, E0148
walker, rigid, adjustable or fixed height, E0130
walker, rigid, wheeled, adjustable or fixed height, E0141
walker, with trunk support, adjystable or fixed height, any, E0140
wheel attachment, rigid, pick up walker, per pair, E0155
Amikacin Sulfate, J0278
Aminolevulinate, J7309
Aminolevulinic acid HCl, J7308
Aminophylline, J0280
Aminolevulinic
Ameluz, J7345
Amiodarone HCl, J0282, J0283 ◀
Amitriptyline HCl, J1320
Ammonia N-13, A9526
Ammonia test paper, A4774
Amnioiwrap2, Q4221
Amnion Bio, Q4211
Amniotic membrane, V2790
Amobarbital, J0300
Amphotericin B, J0285
Lipid Complex, J0287–J0289
Ampicillin
sodium, J0290
 sodium/sulbactam sodium, J0295
Amputee
adapter, wheelchair, E0959
prosthesis, L5000–L7510, L7520, L7900, L8400–L8465
above knee, L5200–L5230
additions to exoskeletal knee-shin systems, L5710–L5782
additions to lower extremity, L5610–L5617
additions to socket insert and suspension, L5654–L5699
additions to socket variations, L5630–L5653
additions to test sockets, L5618–L5629
additions/replacements feet-ankle units, L5700–L5707
ankle, L5050–L5060
below knee, L5100–L5105
component modification, L5785–L5795
endoskeletal, L5810–L5999
endoskeleton, below knee, L5301–L5312
endoskeleton, hip disarticulation, L5331–L5341
fitting endoskeleton, above knee, L5321
fitting procedures, L5400–L5460
hemipelvectomy, L5280
hip disarticulation, L5250–L5270
initial prosthesis, L5500–L5505
knee disarticulation, L5150–L5160
male vacuum erection system, L7900
partial foot, L5000–L5020
preparatory prosthesis, L5510–L5600
prosthetic socks, L8400–L8485
repair, prosthetic device, L7520
tension ring, vacuum erection device, L7902
upper extremity, battery components, L7360–L7368
upper extremity, other/repair, L7400–L7510
upper extremity, preparatory, elbow, L6584–L6586
upper limb, above elbow, L6250
upper limb, additions, L6600–L6698
upper limb, below elbow, L6100–L6130
upper limb, elbow disarticulation, L6200–L6205
upper limb, endoskeletal, above elbow, L6500
upper limb, endoskeletal, below elbow, L6400
upper limb, endoskeletal, elbow disarticulation, L6450
upper limb, endoskeletal, interscapular thoracic, L6570
upper limb, endoskeletal, shoulder disarticulation, L6550
 upper limb, external power, device, L6920–L6975
upper limb, interscapular thoracic, L6350–L6370
upper limb, partial hand, L6000–L6025
upper limb, postsurgical procedures, L6380–L6388
upper limb, preparatory, shoulder, interscapular, L6588–L6590
upper limb, preparatory, wrist, L6580–L6582
upper limb, shoulder disarticulation, L6300–L6320
upper limb, terminal devices, L6703–L6915, L7007–L7261
upper limb, wrist disarticulation, L6050–L6055
stump sock, L8470–L8485
single ply, fitting above knee, L8480
single ply, fitting, below knee, L8470
single ply, fitting, upper limb, L8485
wheelchair, E1170–E1190, E1200, K0100
detachable arms, swing away detachable elevating footrests, E1190
detachable arms, swing away detachable footrests, E1180
detachable arms, without footrests or legrest, E1172
detachable elevating legrest, fixed full length arms, E1170
fixed full length arms, swing away detachable footrest, E1200
heavy duty wheelchair, swing away detachable elevating legrests, E1195
without footrests or legrest, fixed full length arms, E1171
Amygdalin, J3570
Anadulafungin, J0348
Analgesia, dental, D9230
Analysis
saliva, D0418
semen, G0027
Anaphylaxis, due to vaccine, M1160–M1161, M1163 ◀
Angiography, iliac, artery, G0278
Angiography, renal, non-selective, G0275
non-ophthalmic fluorescent vascular, C9733
reconstruction, G0288
Angioplasty, C7531–C7535 ◀
Anistreplase, J0350
Ankle splint, recumbent, K0126–K0130
Ankle-foot orthosis (AFO), L1900–L1990, L2106–L2116, L4361, L4392, L4396
ankle gauntlet, custom fabricated, L1904
ankle gauntlet, prefabricated, off-shelf, L1902
double upright free plantar dorsiflexion, olid stirrup, calf-band/cuff, custom, L1990
fracture orthrosis, tibial fracture, thermoplastic cast material, custom, L2106
multiligamentus ankle support, prefabricated, off-shelf, L1906
 plastic or other material, custom fabricated, L1940
plastic or other material, prefabricated, fitting and adjustment, L1932, L1951
plastic or other material, with ankle joint, prefabricated, fitting and adjustment, L1971
plastic, rigid anterior tibial section, custom fabricated, L1945
plastic, with ankle joint, custom, L1970
posterior, single bar, clasp attachment to shoe, L1910
posterior, solid ankle, plastic, custom, L1960
replacement, soft interface material, static AFO, L4392
single upright free plantar dorsiflection, solid stirrup, calf-band/cuff, custom, L1980
single upright with static or adjustable stop, custom, L1920
spiral, plastic, custom fabricated, L1950
spring wire, dorsiflexion assist calf band, L1900
static or dynamic AFO, adjustable for fit, minimal ambulation, L4396
supramalleolar with straps, custom fabricated, L1907
tibial fracture cast orthrosis, custom, L2108
tibial fracture orthrosis, rigid, prefabricated, fitting and adjustment, L2116
tibial fracture orthrosis, semi-rigid, prefabricated, fitting and adjustment, L2114
tibial fracture orthrosis, soft prefabricated, fitting and adjustment, L2112
walking boot, prefabricated, off-the-shelf, L4361
Anterior-posterior-lateral orthosis, L0700, L0710
Antibiotic, G8708–G8712
antibiotic not prescribed or dispensed, G8712
patient not prescribed or dispensed antibiotic, G8708
patient prescribed antibiotic, documented condition, G8709
patient prescribed or dispensed antibiotic, G8710
prescribed or dispensed antibiotic, G8711
Antidepressant, documentation, G8126–G8128
Anti-emetic, oral, J8498, J8597, Q0163–Q0181
antiemetic drug, oral NOS, J8597
antiemetic drug, rectal suppository, NOS, J8498
diphenhydramine hydrochloride, 50 mg, oral, Q0163
dolasetron mesylate, 100 mg, oral, Q0180
dronabinol, 2.5 mg, Q0167
granisetron hydrochloride, 1 mg, oral, Q0166
hydroxyzine pomoate, 25 mg, oral, Q0177
perphenazine, 4 mg, oral, Q0175
prochlorperazine maleate, 5 mg, oral, Q0164
promethazine hydrochloride, 12.5 mg, oral, Q0169
thiethylperazine maleate, 10 mg, oral, Q0174
trimethobenzamide hydrochloride, 250 mg, oral, Q0173
unspecified oral dose, Q0181
Anti-hemophilic factor (Factor VIII), J7190–J7192
Anti-inhibitors, per I.U., J7198
Antimicrobial, prophylaxis, documentation, D4281, G8201
Anti-neoplastic drug, NOC, J9999
Antithrombin III, J7197
Antithrombin recombinant, J7196
Antral fistula closure, oral, D7260
Apexification, dental, D3351–D3353
Apicoectomy, D3410–D3426
anterior, periradicular surgery, D3410
biscuspid (first root), D3421
(each additional root), D3426
molar (first root), D3425
Apomorphine, J0364
Appliance
cleaner, A5131
pneumatic, E0655–E0673
non-segmental pneumatic appliance, E0655, E0660, E0665, E0666
segmental gradient pressure, pneumatic appliance, E0671–E0673
segmental pneumatic appliance, E0656–E0657, E0667–E0670
Application, heat, cold, E0200–E0239
electric heat pad, moist, E0215
electric heat pad, standard, E0210
heat lamp with stand, E0205
heat lamp without stand, E0200
hydrocollator unit, pads, E0225
hydrocollator unit, portable, E0239
infrared heating pad system, E0221
non-contact wound warming device, E0231
paraffin bath unit, E0235
phototherapy (bilirubin), E0202
pump for water circulating pad, E0236
therapeutic lightbox, E0203
warming card, E0232
water circulating cold pad with pump, E0218
water circulating heat pad with pump, E0217
Aprotinin, J0365
Aqueous
shunt, L8612
sterile, J7051
ARB/ACE therapy, G8473–G8475
Arbutamine HCl, J0395
Arch support, L3040–L3100
hallus-valgus night dynamic splint, off-shelf, L3100
intralesional, J3302
non-removable, attached to shoe, longitudinal, L3070
non-removable, attached to shoe, longitudinal/metatarsal, each, L3090
non-removable, attached to shoe, metatarsal, L3080
removable, premolded, longitudinal, L3040
removable, premolded, longitudinal/metatarsal, each, L3060
removable, premolded, metatarsal, L3050
Arformoterol, J7605
Argatroban, J0883–J0884, J0891–J0892, J0898–J0899 ◀
Aripiprazole, J0400, J0401
Aripiprazol lauroxil, (aristada), J1944
aristada initio, H1943
Arm, wheelchair, E0973
Arsenic trioxide, J9017
Artacent cord, Q4216
Arthrography, injection, sacroiliac, joint, G0259, G0260
Arthroscopy, knee, surgical, G0289, S2112
chondroplasty, different compartment, knee, G0289
harvesting of cartilage, knee, S2112
Artificial
cornea, L8609
heart system, miscellaneous component, supply or accessory, L8698
kidney machines and accessories (see also Dialysis), E1510–E1699
larynx, L8500
saliva, A9155
Ascent, Q4213
Asparaginase, J9019–J9021 ◀
Aspirator, VABRA, A4480
Assessment
alcohol/substance (see also Alcohol/substance, assessment), G0396, G0397, H0001,
H0003, H0049
assessment for hearing aid, V5010
audiologic, V5008–V5020
cardiac output, M0302
conformity evaluation, V5020
fitting/orientation, hearing aid, V5014
hearing screening, V5008
itch severity, M1197–M1198, M1205–M1206 ◀
 repair/modification hearing aid, V5014
speech, V5362–V5364
Assistive listening devices and accessories, V5281–V5290
FMlDM system, monaural, V5281
Astramorph, J2275
Atezolizumab, J9022
Atherectomy, PTCA, C9602, C9603
Atropine
inhalation solution, concentrated, J7635
inhalation solution, unit dose, J7636
Atropine sulfate, J0461
Attachment, walker, E0154–E0159
brake attachment, wheeled walker, replacement, E0159
crutch attachment, walker, E0157
leg extension, walker, E0158
platform attachment, walker, E0154
seat attachment, walker, E0156
wheel attachment, rigid pick up walker, E0155
Audiologic assessment, V5008–V5020
Auditory osseointegrated device, L8690–L8694
Auricular prosthesis, D5914, D5927
Aurothioglucose, J2910
Avalglucosidase alfa-ngpt, J0219 ◀
Avelumab, J9023
Axobiomembrane, Q4211
Axolotl ambient or axolotl cryo, Q4215
Axolotl graft or axolotl dualgraft, Q4210
Azacitidine, J9025
Azathioprine, J7500, J7501
Azithromycin injection, J0456

B
Back supports, L0621–L0861, L0960
lumbar orthrosis, L0625–L0627
lumbar orthrosis, sagittal control, L0641–L0648
lumbar-sacral orthrosis, L0628–L0640
lumbar-sacral orthrosis, sagittal-coronal control, L0640, L0649–L0651
sacroiliac orthrosis, L0621–L0624
Baclofen, J0475, J0476
Bacterial sensitivity study, P7001
Bag
drainage, A4357
enema, A4458
irrigation supply, A4398
urinary, A4358, A5112
Bandage, conforming
elastic, >5″, A6450
elastic, >3″, <5″, A6449
elastic, load resistance 1.25 to 1.34 foot pounds, >3″, <5″, A6451
elastic, load resistance <1.35 foot pounds, >3″, <5″, A6452
elastic, <3″, A6448
non-elastic, non-sterile, >5″, A6444
non-elastic, non-sterile, width greater than or equal to 3″, <5″, A6443
non-elastic, non-sterile, width <3″, A6442
non-elastic, sterile, >5″, A6447
non-elastic, sterile, >3″ and <5″, A6446
Bamlan and etesev, M0245
Bamlanivimab and etesevima, Q0245
Basiliximab, J0480
Bath, aid, E0160–E0162, E0235, E0240–E0249
bath tub rail, floor base, E0242
bath tub wall rail, E0241
bath/shower chair, with/without wheels, E0240
pad for water circulating heat unit, replacement, E0249
paraffin bath unit, portable, E0235
raised toilet seat, E0244
sitz bath chair, E0162
sitz type bath, portable, with faucet attachment, E0161
sitz type bath, portable, with/without commode, E0160
toilet rail, E0243
transfer bench, tub or toilet, E0248
transfer tub rail attachment, E0246
tub stool or bench, E0245
Bathtub
chair, E0240
stool or bench, E0245, E0247–E0248
transfer rail, E0246
wall rail, E0241–E0242
Battery, L7360, L7364–L7368
charger, E1066, L7362, L7366
 replacement for blood glucose monitor, A4233–A4236
replacement for cochlear implant device, L8618, L8623–L8625
replacement for TENS, A4630
ventilator, A4611–A4613
Bebtelovimab, M0222–M0223, Q0222 ◀
Beclomethasone inhalation solution, J7622
Bed
accessories, E0271–E0280, E0300–E0326
bed board, E0273
bed cradle, E0280
bed pan, fracture, metal, E0276
bed pan, standard, metal, E0275
mattress, foam rubber, E0272
mattress innerspring, E0271
over-bed table, E0274
power pressure-reducing air mattress, E0277
air fluidized, E0194
cradle, any type, E0280
drainage bag, bottle, A4357, A5102
hospital, E0250–E0270, E0300–E0329
pan, E0275, E0276
rail, E0305, E0310
safety enclosure frame/canopy, E0316
Behavioral, health, treatment services (Medicaid), H0002–H2037
activity therapy, H2032
alcohol/drug services, H0001, H0003, H0005–H0016, H0020–H0022, H0026–H0029,
H0049–H0050, H2034–H2036
assertive community treatment, H0040
community based wrap-around services, H2021–H2022
comprehensive community support, H2015–H2016
comprehensive medication services, H2010
comprehensive multidisciplinary evaluation, H2000
crisis intervention, H2011
day treatment, per diem, H2013
day treatment, per hour, H2012
developmental delay prevention activities, dependent child of client, H2037
family assessment, H1011
foster care, child, H0041–H0042
health screening, H0002
hotline service, H0030
medication training, H0034
 mental health clubhouse services, H2030–H2031
multisystemic therapy, juveniles, H2033
non-medical family planning, H1010
outreach service, H0023
partial hospitalization, H0035
plan development, non-physician, H0033
prenatal care, at risk, H1000–H1005
prevention, H0024–H0025
psychiatric supportive treatment, community, H0036–H0037
psychoeducational service, H2027
psychoscial rehabilitation, H2017–H2018
rehabilitation program, H2010
residential treatment program, H0017–H0019
respite care, not home, H0045
self-help/peer services, H0039
sexual offender treatment, H2028–H2029
skill training, H2014
supported employment, H2024–H2026
supported housing, H0043–H0044
therapeutic behavioral services, H2019–H2020
Behavioral therapy, cardiovascular disease, G0446
Belatacept, J0485
Belimumab, J0490
Bellacell, Q4220
Belt
belt, strap, sleeve, garment, or covering, any type, A4467
extremity, E0945
ostomy, A4367
pelvic, E0944
safety, K0031
wheelchair, E0978, E0979
Bench, bathtub; (see also Bathtub), E0245
Bendamustine HCl
Bendeka, 1 mg, J9034
Treanda, 1 mg, J9033
Bendamustine HCI (Belrapzo/bendamustine), J9036
Benesch boot, L3212–L3214
Benztropine, J0515
Beta-blocker therapy, G9188–G9192
Betadine, A4246, A4247
Betameth, J0704
Betamethasone
acetate and betamethasone sodium phosphate, J0702
inhalation solution, J7624
Bethanechol chloride, J0520
Bevacizumab, J9035, Q2024
bvzr (Zirabez), Q5118
Bezlotoxuman, J0565
Bicuspid (excluding final restoration), D3320
retreatment, by report, D3347
surgery, first root, D3421
Bifocal, glass or plastic, V2200–V2299
aniseikonic, bifocal, V2218
bifocal add-over 3.25 d, V2220
bifocal seg width over 28 mm, V2219
lenticular, bifocal, myodisc, V2215
lenticular lens, V2221
specialty bifocal, by report, V2200
sphere, bifocal, V2200–V2202
spherocylinder, bifocal, V2203–V2214
Bilirubin (phototherapy) light, E0202
Binder, A4465
Biofeedback device, E0746
Bioimpedance, electrical, cardiac output, M0302
Biosimilar (infliximab), Q5102–Q5124 ◀
BioWound, Q4217
Biperiden lactate, J0190
Bitewing, D0270–D0277
four radiographic images, D0274
single radiographic image, D0270
three radiographic images, D0273
two radiographic images, D0272
vertical bitewings, 7–8 radiographic images, D0277
Bitolterol mesylate, inhalation solution
concentrated, J7628
unit dose, J7629
Bivalirudin, J0583
Bivigam, 500 mg, J1556
Bladder calculi irrigation solution, Q2004
Bleomycin sulfate, J9040
Blood
count, G0306, G0307, S3630
 complete CBC, automated, without platelet count, G0307
complete CBC, automated without platelet count, automated WBC differential, G0306
eosinophil count, blood, direct, S3630
component/product not otherwise classified, P9099
fresh frozen plasma, P9017
glucose monitor, E0607, E2100–E2102, S1030, S1031, S1034
blood glucose monitor, integrated voice synthesizer, E2100
blood glucose monitor with integrated lancing/blood sample, E2101
continuous noninvasive device, purchase, S1030
continuous noninvasive device, rental, S1031
home blood glucose monitor, E0607
glucose test, A4253
glucose, test strips, dialysis, A4772
granulocytes, pheresis, P9050
ketone test, A4252
leak detector, dialysis, E1560
leukocyte poor, P9016
mucoprotein, P2038
platelets, P9019
platelets, irradiated, P9032
platelets, leukocytes reduced, P9031
platelets, leukocytes reduced, irradiated, P9033
platelets, pheresis, P9034, P9072, P9073, P9100
platelets, pheresis, irradiated, P9036
platelets, pheresis, leukocytes reduced, P9035
platelets, pheresis, leukocytes reduced, irradiated, P9037
pressure monitor, A4660, A4663, A4670
pump, dialysis, E1620
red blood cells, deglycerolized, P9039
red blood cells, irradiated, P9038
red blood cells, leukocytes reduced, P9016
red blood cells, leukocytes reduced, irradiated, P9040
red blood cells, washed, P9022
strips, A4253
supply, P9010–P9022
testing supplies, A4770
tubing, A4750, A4755
Blood collection devices accessory, A4257, E0620
BMI, G8417–G8422
Body jacket
scoliosis, L1300, L1310
Body mass index, G8417–G8422
Body sock, L0984
Bond or cement, ostomy skin, A4364
Bone
density, study, G0130
Boot
pelvic, E0944
surgical, ambulatory, L3260
Bortezomib, J9041, J9046, J9048–J9049 ◀
Brachytherapy radioelements, Q3001
brachytherapy, LDR, prostate, G0458
brachytherapy planar source, C2645
brachytherapy, source, hospital outpatient, C1716–C1717, C1719
Breast prosthesis, L8000–L8035, L8600
adhesive skin support, A4280
custom breast prosthesis, post mastectomy, L8035
garment with mastectomy form, post mastectomy, L8015
implantable, silicone or equal, L8600
mastectomy bra, with integrated breast prosthesis form, unilateral, L8001
mastectomy bra, with prosthesis form, bilateral, L8002
mastectomy bra, without integrated breast prosthesis form, L8000
mastectomy form, L8020
mastectomy sleeve, L8010
nipple prosthesis, L8032
silicone or equal, with integral adhesive, L8031
silicone or equal, without integral adhesive, L8030
Breast pump
accessories, A4281–A4286
adapter, replacement, A4282
cap, breast pump bottle, replacement, A4283
locking ring, replacement, A4286
polycarbonate bottle, replacement, A4285
shield and splash protector, replacement, A4284
tubing, replacement, A4281
electric, any type, E0603
heavy duty, hospital grade, E0604
manual, any type, E0602
Breathing circuit, A4618
Brentuximab Vedotin, J9042
Brexanolone, J1632
Bridge
 repair, by report, D6980
replacement, D6930
Bronchoscopy, C7509–C7512 ◀
Brolucizumab-dbll, J0179
Brompheniramine maleate, J0945
Budesonide inhalation solution, J7626, J7627, J7633, J7634
Bulking agent, L8604, L8607
Bupivacaine, C9144 ◀
Buprenorphine hydrochlorides, J0592
Buprenorphine/Naloxone, J0571–J0575
Burn, compression garment, A6501–A6513
bodysuit, head-foot, A6501
burn mask, face and/or neck, A6513
chin strap, A6502
facial hood, A6503
foot to knee length, A6507
foot to thigh length, A6508
glove to axilla, A6506
glove to elbow, A6505
glove to wrist, A6504
lower trunk, including leg openings, A6511
trunk, including arms, down to leg openings, A6510
upper trunk to waist, including arm openings, A6509
Bus, nonemergency transportation, A0110
Busulfan, J0594, J8510
Butorphanol tartrate, J0595
Bypass, graft, coronary, artery
surgery, S2205–S2209

C
C-1 Esterase Inhibitor, J0596–J0598
Cabazitaxel, J9043
Cabergoline, oral, J8515
Cabinet/System, ultraviolet, E0691–E0694
multidirectional light system, 6 ft. cabinet, E0694
timer and eye protection, 4 foot, E0692
timer and eye protection, 6 foot, E0693
ultraviolet light therapy system, treatment area 2 sq ft., E0691
Cabote rilpivir J0741
Cabotegravir, J0739 ◀
Caffeine citrate, J0706
Calaspargase pegol injection-mknl, J9118
Calcitonin-salmon, J0630
Calcitriol, J0636, S0169
Calcium
disodium edetate, J0600
gluconate, J0610, J0611 ◀
glycerophosphate and calcium lactate, J0620
lactate and calcium glycerophosphate, J0620
leucovorin, J0640
Calibrator solution, A4256
Camcevi, J1952
Canakinumab, J0638
Cancer, screening
cervical or vaginal, G0101
colorectal, G0104–G0106, G0120–G0122, G0328
alternative to screening colonoscopy, barium enema, G0120
alternative to screening sigmoidoscopy, barium enema, G0106
barium enema, G0122
colonoscopy, high risk, G0105
colonoscopy, not at high-risk, G0121
fecal occult blood test, 1-3 simultaneous, G0328
flexible sigmoidoscopy, G0104
prostate, G0102, G0103
Cane, E0100, E0105
accessory, A4636, A4637
Canister
disposable, used with suction pump, A7000
non-disposable, used with suction pump, A7001
Cannula, nasal, A4615
Capecitabine, oral, J8520, J8521
Capsaicin patch, J7336
Carbidopa 5 mg/levodopa 20 mg enteral suspension, J7340
Carbon filter, A4680
Carboplatin, J9045
Cardia Event, recorder, implantable, E0616
Cardiokymography, Q0035
Cardiovascular services, M0300–M0301
Fabric wrapping abdominal aneurysm, M0301
IV chelation therapy, M0300
Cardioverter-defibrillator, G0448
Care ◀
cancer, M0001 ◀
optimal, M0002–M0003 ◀
supportive, M0004 ◀
Care, coordinated, G9001–G9011, H1002
coordinated care fee, home monitoring, G9006
coordinated care fee, initial rate, G9001
coordinated care fee, maintenance rate, G9002
coordinated care fee, physician coordinated care oversight, G9008
coordinated care fee, risk adjusted high, initial, G9003
coordinated care fee, risk adjusted low, initial, G9004
coordinated care fee, risk adjusted maintenance, G9005
coordinated care fee, risk adjusted maintenance, level 3, G9009
coordinated care fee, risk adjusted maintenance, level 4, G9010
coordinated care fee, risk adjusted maintenance, level 5, G9011
coordinated care fee, scheduled team conference, G9007
prenatal care, at-risk, enhanced service, care coordination, H1002
Care plan, G0162
Carfilzomib, J9047
Caries susceptibility test, D0425
Carmustine, J9050
Case management, T1016, T1017
behavioral health, G0323 ◀
dental, D9991–D9994
Casimersen J1426
Caspofungin acetate, J0637
Cast
diagnostic, dental, D0470
hand restoration, L6900–L6915
materials, special, A4590
supplies, A4580, A4590, Q4001–Q4051
body cast, adult, Q4001–Q4002
cast supplies (e.g., plaster), A4580
cast supplies, unlisted types, Q4050
finger splint, static, Q4049
gauntlet cast, adult, Q4013–Q4014
gauntlet cast, pediatric, Q4015–Q4016
hip spica, adult, Q4025–Q4026
hip spica, pediatric, Q4027–Q4028
long arm cast, adult, Q4005–Q4006
 long arm cast, pediatric, Q4007–Q4008
long arm splint, adult, Q4017–Q4018
long arm splint, pediatric, Q4019–Q4020
long leg cast, adult, Q4029–Q4030
long leg cast, pediatric, Q4031–Q4032
long leg cylinder cast, adult, Q4033–Q4034
long leg cylinder cast, pediatric, Q4035–Q4036
long leg splint, adult, Q4041–Q4042
long leg splint, pediatric, Q4043–Q4044
short arm cast, adult, Q4009–Q4010
short arm cast, pediatric, Q4011–Q4012
short arm splint, adult, Q4021–Q4022
short arm splint, pediatric, Q4023–Q4024
short leg cast, adult, Q4037–Q4038
short leg cast, pediatric, Q4039–Q4040
short leg splint, adult, Q4045–Q4046
short leg splint, pediatric, Q4047–Q4048
shoulder cast, adult, Q4003–Q4004
special casting material (fiberglass), A4590
splint supplies, miscellaneous, Q4051
thermoplastic, L2106, L2126
Caster
front, for power wheelchair, K0099
wheelchair, E0997, E0998
Catheter, A4300–A4355
anchoring device, A4333, A4334, A5200
cap, disposable (dialysis), A4860
convert, C7547 ◀
coronary artery, C7516–C7529, C7552–C7553 ◀
exchange, C7548 ◀
external collection device, A4327–A4330, A4347–A7048
female external, A4327–A4328
indwelling, A4338–A4346
insertion tray, A4354
insulin infusion catheter, A4224
intermittent with insertion supplies, A4353
irrigation supplies, A4355
male external, A4324, A4325, A4326, A4348
nephroureteral, C7546 ◀
oropharyngeal suction, A4628
starter set, A4329
 trachea (suction), A4609, A4610, A4624
transluminal angioplasty, C2623
transtracheal oxygen, A4608
vascular, A4300–A4301
Catheterization, specimen collection, P9612, P9615
CBC, G0306, G0307
Cefazolin sodium, J0689, J0690 ◀
Cefepime HCl, J0692, J0701, J0703 ◀
Cefiderocol, J0699
Cefotaxime sodium, J0698
Ceftaroline fosamil, J0712
Ceftazidime, J0713, J0714
Ceftizoxime sodium, J0715
Ceftolozane 50 mg and tazobactam 25 mg, J0695
Ceftriaxone sodium, J0696
Cefuroxime sodium, J0697
Celera, Q4259 ◀
CellCept, K0412
Cellesta cord, Q4214
Cellesta or cellesta duo, Q4184
Cellular therapy, M0075
Cement, ostomy, A4364
Cemiplimab injection-rwlc, J9119
Centrifuge, A4650
Centruroides Immune F(ab), J0716
Cephalin Floculation, blood, P2028
Cephalothin sodium, J1890
Cephapirin sodium, J0710
Certification, physician, home, health (per calendar month), G0179–G0182
Physician certification, home health, G0180
Physician recertification, home health, G0179
Physician supervision, home health, complex care, 30 min or more, G0181
Physician supervision, hospice 30 min or more, G0182
Certolizumab pegol, J0717
Cerumen, removal, G0268
Cervical
cancer, screening, G0101
cytopathology, G0123, G0124, G0141–G0148
screening, automated thin layer, manual rescreening, physician supervision, G0145
screening, automated thin layer preparation, cytotechnologist, physician interpretation,
G0143
 screening, automated thin layer preparation, physician supervision, G0144
screening, by cytotechnologist, physician supervision, G0123
screening, cytopathology smears, automated system, physician interpretation, G0141
screening, interpretation by physician, G0124
screening smears, automated system, manual rescreening, G0148
screening smears, automated system, physician supervision, G0147
halo, L0810–L0830
head harness/halter, E0942
orthosis, L0100–L0200
cervical collar molded to patient, L0170
cervical, flexible collar, L0120–L0130
cervical, multiple post collar, supports, L0180–L0200
cervical, semi-rigid collar, L0150–L0160, L0172, L0174
cranial cervical, L0112–L0113
traction, E0855, E0856
Cervical cap contraceptive, A4261
Cervical-thoracic-lumbar-sacral orthosis (CTLSO), L0700, L0710
Cetuximab, J9055
Chair
adjustable, dialysis, E1570
lift, E0627
rollabout, E1031
sitz bath, E0160–E0162
transport, E1035–E1039
chair, adult size, heavy duty, greater than 300 pounds, E1039
chair, adult size, up to 300 pounds, E1038
chair, pediatric, E1037
multi-positional patient transfer system, extra-wide, greater than 300 pounds, E1036
multi-positional patient transfer system, up to 300 pounds, E1035
Change ◀
ureterostomy tube, C7549 ◀
Chaplain Services, Q9001–Q9003 ◀
Chelation therapy, M0300
Chemical endarterectomy, M0300
Chemistry and toxicology tests, P2028–P3001
Chemotherapy
administration (hospital reporting only), Q0083–Q0085
drug, oral, not otherwise classified, J8999
drugs; (see also drug by name), J9000–J9999
Chest shell (cuirass), E0457
Chest Wall Oscillation System, E0483
 hose, replacement, A7026
vest, replacement, A7025
Chest wrap, E0459
Chin cup, cervical, L0150
Chloramphenicol sodium succinate, J0720
Chlordiazepoxide HCl, J1990
Chloromycetin sodium succinate, J0720
Chloroprocaine HCl, J2400,✖ J2401–J2402 ◀
Chloroquine HCl, J0390
Chlorothiazide sodium, J1205
Chlorpromazine HCl, J3230
Chlorpromazine HCL, 5 mg, oral, Q0161
Chorionic gonadotropin, J0725
Choroid, lesion, destruction, G0186
Chromic phosphate P32 suspension, A9564
Chromium CR-51 sodium chromate, A9553
Cidofovir, J0740
Cilastatin sodium, imipenem, J0743
Ciltacabtagene, Q2056 ◀
Cinacalcet, J0604
Ciprofloxacin
for intravenous infusion, J0744
octic suspension, J7342
Cisplatin, J9060
Cladribine, J9065
Clamp
dialysis, A4918
external urethral, A4356
Cleanser, wound, A6260
Cleansing agent, dialysis equipment, A4790
Clofarabine, J9027
Clonidine, J0735
Closure, wound, adhesive, tissue, G0168
Clotting time tube, A4771
Clubfoot wedge, L3380
Cocaine, C9143 ◀
Cochlear prosthetic implant, L8614
accessories, L8615–L8617, L8618
batteries, L8621–L8624
replacement, L8619, L8627–L8629
external controller component, L8628
 external speech processor and controller, integrated system, L8619
external speech processor, component, L8627
transmitting coil and cable, integrated, L8629
Cocoon, membrane, Q4264 ◀
Codeine phosphate, J0745
Cold/Heat, application, E0200–E0239
bilirubin light, E0202
electric heat pad, moist, E0215
electric heat pad, standard, E0210
heat lamp with stand, E0205
heat lamp, without stand, E0200
hydrocollator unit, E0225
hydrocollator unit, portable, E0239
infrared heating pad system, E0221
non-contact wound warming device, E0231
paraffin bath unit, E0235
pump for water circulating pad, E0236
therapeutic lightbox, E0203
warming card, non-contact wound warming device, E0232
water circulating cold pad, with pump, E0218
water circulating heat pad, with pump, E0217
Colistimethate sodium, J0770
Collagen
meniscus implant procedure, G0428
skin test, G0025
urinary tract implant, L8603
wound dressing, A2006–A2014, A6020–A6024 ◀
Collagenase, Clostridium histolyticum, J0775
Collar, cervical
multiple post, L0180–L0200
nonadjust (foam), L0120
Collection and preparation, saliva, D0417
Colorectal, screening, cancer, G0104–G0106, G0120–G0122, G0328
Coly-Mycin M, J0770
Comfort items, A9190
Commode, E0160–E0175
chair, E0170–E0171
lift, E0172, E0625
pail, E0167
seat, wheelchair, E0968
Complete, blood, count, G0306, G0307
Composite dressing, A6200–A6205
Compressed gas system, E0424–E0446
oximeter device, E0445
portable gaseous oxygen system, purchase, E0430
portable gaseous oxygen system, rental, E0431
portable liquid oxygen, rental, container/supplies, E0434
portable liquid oxygen, rental, home liquefier, E0433
portable liquid oxygen system, purchase, container/refill adapter, E0435
portable oxygen contents, gaseous, 1 month, E0443
portable oxygen contents, liquid, 1 month, E0444
stationary liquid oxygen system, purchase, use of reservoir, E0440
stationary liquid oxygen system, rental, container/supplies, E0439
stationary oxygen contents, gaseous, 1 month, E0441
stationary oxygen contents, liquid, 1 month, E0442
stationary purchase, compressed gas system, E0425
stationary rental, compressed gaseous oxygen system, E0424
topical oxygen delivery system, NOS, E0446
Compression
bandage, A4460
burn garment, A6501–A6512
stockings, A6530–A6549
Compressor, E0565, E0570, E0571, E0572, E0650–E0652, K1031–K1033 ◀
Conductive gel/paste, A4558
Conductivity meter, bath, dialysis, E1550
Conference, team, G0175, G9007, S0220, S0221
coordinate care fee, scheduled team conference, G9007
medical conference/physician/interdisciplinary team, patient present, 30 min, S0220
medical conference physician/interdisciplinary team, patient present, 60 min, S0221
scheduled interdisciplinary team conference, patient present, G0175
Congo red, blood, P2029
Consultation, S0285, S0311, T1040, T1041
dental, D9311
Telehealth, G0425–G0427
Contact layer, A6206–A6208
Contact lens, V2500–V2599
Continent device, A5081, A5082, A5083
Continuous glucose monitoring system
receiver, A9278, E2103, S1037 ◀
sensor, A9276, S1035
transmitter, A9277, S1036
Continuous passive motion exercise device, E0936
Continuous positive airway pressure device(CPAP), E0601
compressor, K0269
Contraceptive
cervical cap, A4261
condoms, A4267, A4268
diaphragm, A4266
intratubal occlusion device, A4264
intrauterine, copper, J7300
intrauterine, levonorgestrel releasing, J7296–J7298, J7301
patch, J7304
spermicide, A4269
supply, A4267–A4269
vaginal ring, J7303
Contracts, maintenance, ESRD, A4890
Contrast, Q9951–Q9969
HOCM, Q9958–Q9964
injection, iron based magnetic resonance, per ml, Q9953
injection, non-radioactive, non-contrast, visualization adjunct, Q9968
injection, octafluoropropane microspheres, per ml, Q9956
injection, perflexane lipid microspheres, per ml, Q9955
injection, perflutren lipid microspheres, per ml, Q9957
LOCM, Q9965–Q9967
LOCM, 400 or greater mg/ml iodine, per ml, Q9951
oral magnetic resonance contrast, Q9954
Tc-99m per study dose, Q9969
Contrast material
injection during MRI, A4643
low osmolar, A4644–A4646
Coordinated, care, G9001–G9011
CORF, registered nurse- face-face, G0128
Corneal tissue processing, V2785
Corset, spinal orthosis, L0970–L0976
LSO, corset front, L0972
LSO, full corset, L0976
TLSO, corset front, L0970
TLSO, full corset, L0974
Corticorelin ovine triflutate, J0795
Corticotropin, J0800
Corvert (see Ibutilide fumarate)
Cosyntropin, J0833, J0834
Cough stimulating device, A7020, E0482
Counseling
alcohol misuse, G0443
cardiovascular disease, G0448
control of dental disease, D1310, D1320
immunization, G0310–G0315 ◀
obesity, G0447
sexually transmitted infection, G0445
Count, blood, G0306, G0307
Counterpulsation, external, G0166
Cover, wound
alginate dressing, A6196–A6198
foam dressing, A6209–A6214
hydrogel dressing, A6242–A6248
non-contact wound warming cover, and accessory, A6000, E0231, E0232
specialty absorptive dressing, A6251–A6256
Covid test, K1034 ◀
CPAP (continuous positive airway pressure) device, E0601
headgear, K0185
humidifier, A7046
intermittent assist, E0452
Cradle, bed, E0280
Cranial electrotherapy stimulation (CES), K1002
Crib, E0300
Cromolyn sodium, inhalation solution, unit dose, J7631, J7632
Crotalidae polyvalent immune fab, J0840
Crowns, D2710–D2983, D4249, D6720–D6794
clinical crown lengthening-hard tissue, D4249
fixed partial denture retainers, crowns, D6710–D6794
single restoration, D2710–D2983
Crutches, E0110–E0118
accessories, A4635–A4637, K0102
crutch substitute, lower leg, E0118
forearm, E0110–E0111
underarm, E0112–E0117
Cryoprecipitate, each unit, P9012
CTLSO, L0700, L0710, L1000–L1120
addition, axilla sling, L1010
addition, cover for upright, each, L1120
addition, kyphosis pad, L1020
addition, kyphosis pad, floating, L1025
addition, lumbar bolster pad, L1030
 addition, lumbar rib pad, L1040
addition, lumbar sling, L1090
addition, outrigger, L1080
addition, outrigger bilateral, vertical extensions, L1085
addition, ring flange, L1100
addition, ring flange, molded to patient model, L1110
addition, sternal pad, L1050
addition, thoracic pad, L1060
addition, trapezius sling, L1070
anterior-posterior-lateral control, molded to patient model (CTLSO), L0710
cervical, thoracic, lumbar, sacral orthrosis (CTLSO), L0700
furnishing initial orthrosis, L1000
immobilizer, infant size, L1001
tension based scoliosis orthosis, fitting, L1005
Cuirass, E0457
Culture sensitivity study, P7001
Cushion, wheelchair, E0977
Cutaquig, J1551 ◀
Cyanocobalamin Cobalt C057, A9559
Cycler dialysis machine, E1594
Cyclophosphamide, J9070, J9071 ◀
oral, J8530
Cyclosporine, J7502, J7515, J7516
Cygnus matrix, Q4199
Cystourethroscopy, C7550, C7554 ◀
Cytarabine, J9100
liposome, J9098
Cytomegalovirus immune globulin (human), J0850
Cytopathology, cervical or vaginal, G0123, G0124, G0141–G0148
 D
Dacarbazine, J9130
Daclizumab, J7513
Dactinomycin, J9120
Dalalone, J1100
Dalbavancin, 5mg, J0875
Dalteparin sodium, J1645
Daptomycin, J0877, J0878 ◀
Daratumumab, J9144, J9145
Darbepoetin Alfa, J0881–J0882
Daunorubicin
Citrate, J9151
HCl, J9150
DaunoXome (see Daunorubicin citrate)
Debridement
bone, C7500 ◀
Decitabine, J0893, J0894 ◀
Decubitus care equipment, E0180–E0199
air fluidized bed, E0194
air pressure mattress, E0186
air pressure pad, standard mattress, E0197
dry pressure mattress, E0184
dry pressure pad, standard mattress, E0199
gel or gel-like pressure pad mattress, standard, E0185
gel pressure mattress, E0196
heel or elbow protector, E0191
positioning cushion, E0190
power pressure reducing mattress overlay, with pump, E0181, E0183 ◀
powered air flotation bed, E0193
pump, alternating pressure pad, replacement, E0182
synthetic sheepskin pad, E0189
water pressure mattress, E0187
water pressure pad, standard mattress, E0198
Deferoxamine mesylate, J0895
Defibrillator, external, E0617, K0606
battery, K0607
electrode, K0609
garment, K0608
Degarelix, J9155
Deionizer, water purification system, E1615
Delivery/set-up/dispensing, A9901
Denileukin diftitox, J9160
Denosumab, J0897
Density, bone, study, G0130
Dental procedures
adjunctive general services, D9110–D9999
alveoloplasty, D7310–D7321
analgesia, D9230
diagnostic, D0120–D0999
endodontics, D3000–D3999
evaluations, D0120–D0180
implant services, D6000–D6199
implants, D3460, D5925, D6010–D6067, D6075–D6199
laboratory, D0415–D0999
maxillofacial, D5900–D5999
orthodontics, D8000–D8999
periodontics, D4000–D4999
preventive, D1000–D1999
prosthetics, D5911–D5960, D5999
prosthodontics, fixed, D6200–D6999
prosthodontics, removable, D5000–D5999
restorative, D2000–D2999
scaling, D4341–D4346, D6081
Dentures, D5110–D5899
Depo-estradiol cypionate, J1000
Dermacell, dermacell awn or dermacell awn porous, Q4122
Dermal filler injection, G0429
Desmopressin acetate, J2597
Destruction, lesion, choroid, G0186
Detector, blood leak, dialysis, E1560
Developmental testing, G0451
Devices, other orthopedic, E1800–E1841
assistive listening device, V5267–V5290
Dexamethasone
acetate, J1094
inhalation solution, concentrated, J7637
inhalation solution, unit dose, J7638
intravitreal implant, J7312
lacrimal ophthalmic insert, J1096
 oral, J8540
sodium phosphate, J1100
Dextran, J7100
Dextrose
saline (normal), J7042
water, J7060, J7070
Dextrose, 5% in lactated ringers infusion, J7121
Dextrostick, A4772
Diabetes
evaluation, G0245, G0246
shoes (fitting/modifications), A5500–A5508
deluxe feature, depth-inlay shoe, A5508
depth inlay shoe, A5500
molded from cast patient’s foot, A5501
shoe with metatarsal bar, A5505
shoe with off-set heel(s), A5506
shoe with rocker or rigid-bottom rocker, A5503
shoe with wedge(s), A5504
specified modification NOS, depth-inlay shoe, A5507
training, outpatient, G0108, G0109
Diagnostic
dental services, D0100–D0999
copper, A9592
florbetaben, Q9983
flutemetamol F18, Q9982
mammography, digital image, G9899, G9900
radiology services, R0070–R0076
Dialysate
concentrate additives, A4765
solution, A4720–A4728
testing solution, A4760
Dialysis
air bubble detector, E1530
bath conductivity, meter, E1550
chemicals/antiseptics solution, A4674
circuit, C7513–C7515, C7530 ◀
disposable cycler set, A4671
emergency, G0257
equipment, E1510–E1702
extension line, A4672–A4673
filter, A4680
 fluid barrier, E1575
home, S9335, S9339
kit, A4820
pressure alarm, E1540
shunt, A4740
supplies, A4650–A4927
tablo hemodialysis system, E1629
tourniquet, A4929
unipuncture control system, E1580
unscheduled, G0257
venous pressure clamp, A4918
Dialyzer, A4690
Diaper, T1500, T4521–T4540, T4543, T4544
adult incontinence garment, A4520, A4553
incontinence supply, rectal insert, any type, each, A4337
disposable penile wrap, T4545
Diathermy low frequency ultrasonic treatment device for home use, K1004
Diazepam, J3360
Diazoxide, J1730
Diclofenac, J1130
Dicyclomine HCl, J0500
Diethylstilbestrol diphosphate, J9165
Difelikefalin (for ESRD on dialysis), J0879 ◀
Digital behavioral therapy, A9291 ◀
Digoxin, J1160
Digoxin immune fab (ovine), J1162
Dihydroergotamine mesylate, J1110
Dimenhydrinate, J1240
Dimercaprol, J0470
Dimethyl sulfoxide (DMSO), J1212
Diphenhydramine HCl, J1200
Dipyridamole, J1245
Disarticulation
lower extremities, prosthesis, L5000–L5999
above knee, L5200–L5230
additions exoskeletal-knee-shin system, L5710–L5782
additions to lower extremities, L5610–L5617
additions to socket insert, L5654–L5699
additions to socket variations, L5630–L5653
additions to test sockets, L5618–L5629
additions/replacements, feet-ankle units, L5700–L5707
 ankle, L5050–L5060
below knee, L5100–L5105
component modification, L5785–L5795
endoskeletal, L5810–L5999
endoskeletal, above knee, L5321
endoskeletal, hip disarticulation, L5331–L5341
endoskeleton, below knee, L5301–L5312
hemipelvectomy, L5280
hip disarticulation, L5250–L5270
immediate postsurgical fitting, L5400–L5460
initial prosthesis, L5500–L5505
knee disarticulation, L5150–L5160
partial foot, L5000–L5020
preparatory prosthesis, L5510–L5600
upper extremities, prosthesis, L6000–L6692
above elbow, L6250
additions to upper limb, L6600–L6698
below elbow, L6100–L6130
elbow disarticulation, L6200–L6205
endoskeletal, below elbow, L6400
endoskeletal, interscapular thoracic, L6570–L6590
endoskeletal, shoulder disarticulation, L6550
immediate postsurgical procedures, L6380–L6388
interscapular/thoracic, L6350–L6370
partial hand, L6000–L6026
shoulder disarticulation, L6300–L6320
wrist disarticulation, L6050–L6055
Disease
status, oncology, G9063–G9139
Dispensing, fee, pharmacy, G0333, Q0510–Q0514, S9430
dispensing fee inhalation drug(s), 30 days, Q0513
dispensing fee inhalation drug(s), 90 days, Q0514
inhalation drugs, 30 days, as a beneficiary, G0333
initial immunosuppressive drug(s), post transplanr, G0510
oral anti-cancer, oral anti-emetic, immunosuppressive, first prescription, Q0511
oral anti-cancer, oral anti-emetic, immunosuppressive, subsequent preparation, Q0512
Disposable collection and storage bag for breast milk, K1005
Disposable supplies, ambulance, A0382, A0384, A0392–A0398
DME
miscellaneous, A9900–A9999
DME delivery, set up, A9901
 DME supple, NOS, A9999
DME supplies, A9900
DMSO, J1212
Dobutamine HCl, J1250
Docetaxel, J9171
Documentation
antidepressant, G8126–G8128
blood pressure, G8476–G8478
bypass, graft, coronary, artery, documentation, G8160–G8163
CABG, G8160–G8163
dysphagia, G8232
dysphagia, screening, G8232, V5364
ECG, 12–lead, G8705, G8706
eye, functions, G8315–G8333
influenza, immunization, G8482–G8484, M1169 ◀
kidney health evaluation, M1189–M1190 ◀
medical reason, M1178, M1183–M1185, M1194, M1201–M1202 ◀
pharmacologic therapy for osteoporosis, G8635
physician for DME, G0454
prophylactic antibiotic, G8702, G8703
prophylactic parenteral antibiotic, G8629–G8632
prophylaxis, DVT, G8218
prophylaxis, thrombosis, deep, vein, G8218
urinary, incontinence, G8063, G8267
vaccine, immunization, M1172 ◀
Dolasetron mesylate, J1260
Dome and mouthpiece (for nebulizer), A7016
Dopamine HCl, J1265
Doripenem, J1267
Dornase alpha, inhalation solution, unit dose form, J7639
Dostarlimab-gxly, J9272 ◀
Doxercalciferol, J1270
Doxil, J9001
Doxorubicin HCl, J9000, J9002
Drainage
bag, A4357, A4358
board, postural, E0606
bottle, A5102
Dressing
alginate, A6196–A6199
collagen, A6020–A6024
 composite, A6200–A6205
contact layer, A6206–A6208
foam, A6209–A6215
gauze, A6216–A6230, A6402–A6406
holder/binder, A4462
hydrocolloid, A6234–A6241
hydrogel, A6242–A6248
specialty absorptive, A6251–A6256
transparent film, A6257–A6259
tubular, A6457
wound, K0744–K0746
Droperidol, J1790
and fentanyl citrate, J1810
Dropper, A4649
Drugs; (see also Table of Drugs)
administered through a metered dose inhaler, J3535
antiemetic, J8498, J8597, Q0163–Q0181
chemotherapy, J8500–J9999
disposable delivery system, 50 ml or greater per hour, A4305
disposable delivery system, 5 ml or less per hour, A4306
immunosuppressive, J7500–J7599
infusion supplies, A4221, A4222, A4230–A4232
inhalation solutions, J7608–J7699
non-prescription, A9150
not otherwise classified, J3490, J7599, J7699, J7799, J7999, J8499, J8999, J9999
oral, NOS, J8499
prescription, oral, J8499, J8999
Dry pressure pad/mattress, E0179, E0184, E0199
Duel layer impax membrane, Q4262 ◀
Durable medical equipment (DME), E0100–E1830, K Codes
additional oxygen related equipment, E1352–E1406
arm support, wheelchair, E2626–E2633
artificial kidney machines/accessories, E1500–E1699
attachments, E0156–E0159
bath and toilet aides, E0240–E0249
canes, E0100–E0105
commodes, E0160–E0175
crutches, E0110–E0118
decubitus care equipment, E0181–E0199
DME, respiratory, inexpensive, purchased, A7000–A7509
gait trainer, E8000–E8002
 heat/cold application, E0200–E0239
hospital beds and accessories, E0250–E0373
humidifiers/nebulizers/compressors, oxygen IPPB, E0550–E0585
infusion supplies, E0776–E0791
IPPB machines, E0500
jaw motion rehabilitation system, E1700–E1702
miscellaneous, E1902–E2120
monitoring equipment, home glucose, E0607
negative pressure, E2402
other orthopedic devices, E1800–E1841
oxygen/respiratory equipment, E0424–E0487
pacemaker monitor, E0610–E0620
patient lifts, E0621–E0642
pneumatic compressor, E0650–E0676
rollout chair/transfer system, E1031–E1039
safety equipment, E0700–E0705
speech device, E2500–E2599
suction pump/room vaporizers, E0600–E0606
temporary DME codes, regional carriers, K0000–K9999
TENS/stimulation device(s), E0720–E0770
traction equipment, E0830–E0900
trapeze equipment, fracture frame, E0910–E0948
walkers, E0130–E0155
wheelchair accessories, E2201–E2397
wheelchair, accessories, E0950–E1030
wheelchair, amputee, E1170–E1200
wheelchair cusion/protection, E2601–E2621
wheelchair, fully reclining, E1050–E1093
wheelchair, heavy duty, E1280–E1298
wheelchair, lightweight, E1240–E1270
wheelchair, semi-reclining, E1100–E1110
wheelchair, skin protection, E2622–E2625
wheelchair, special size, E1220–E1239
wheelchair, standard, E1130–E1161
whirlpool equipment, E1300–E1310
Duraclon, (see Clonidine)
Dyphylline, J1180
Dysphagia, screening, documentation, G8232, V5364
Dystrophic, nails, trimming, G0127
 E
Ear mold, V5264, V5265
Ecallantide, J1290
Echocardiography injectable contrast material, A9700
ECG, 12–lead, G8704
Eculizumab, J1300
ED, visit, G0380–G0384
Edetate
calcium disodium, J0600
disodium, J3520
Educational Services
chronic kidney disease, G0420, G0421
Efgartigimod, J9332 ◀
Eggcrate dry pressure pad/mattress, E0184, E0199
EKG, G0403–G0405
Elbow
disarticulation, endoskeletal, L6450
orthosis (EO), E1800, L3700–L3740, L3760, L3671
dynamic adjustable elbow flexion device, E1800
elbow arthrosis, L3702–L3766
protector, E0191
Electric hand, L7007–L7008
Electric, nerve, stimulator, transcutaneous, A4595, E0720–E0749
conductive garment, E0731
electric joint stimulation device, E0762
electrical stimulator supplies, A4595, A4596 ◀
electromagnetic wound treatment device, E0769
electronic salivary reflex stimulator, E0755
EMG, biofeedback device, E0746
functional electrical stimulator, nerve and/or muscle groups, E0770
functional stimulator sequential muscle groups, E0764
incontinence treatment system, E0740
nerve stimulator (FDA), treatment nausea and vomiting, E0765
osteogenesis stimulator, electrical, surgically implanted, E0749
osteogenesis stimulator, low-intensity ultrasound, E0760
osteogenesis stimulator, non-invasive, not spinal, E0747
osteogenesis stimulator, non-invasive, spinal, E0748
radiowaves, non-thermal, high frequency, E0761
stimulator, electrical shock unit, E0745
 stimulator for scoliosis, E0744
TENS, four or more leads, E0730
TENS, two lead, E0720
Electrical stimulation device used for cancer treatment, E0766
Electrical work, dialysis equipment, A4870
Electrodes, per pair, A4555, A4556
Electromagnetic, therapy, G0295, G0329
Electronic medication compliance, T1505
Electronic positional obstructive sleep apnea treatment, K1001
Elevating leg rest, K0195
Elliotts B solution, J9175
Elotuzumab, J9176
Emapalumab injection-lzsg, J9210
Emergency department, visit, G0380–G0384
EMG, E0746
Eminase, J0350
Encephalitis, due to vaccine, M1162 ◀
Endarterectomy, chemical, M0300
Endodontic procedures, D3000–D3999
periapical services, D3410–D3470
pulp capping, D3110, D3120
root canal therapy, D3310–D3353
therapy, D3310–D3330
Endodontics, dental, D3000–D3999
Endoscope sheath, A4270
Endoscopic
retrograde cholangiopancreatography, C7541–C7544 ◀
Endoskeletal system, addition, L5848, L5856–L5857, L5925, L5961, L5969
Enema, bag, A4458
Enfuvirtide, J1324
Enoxaparin sodium, J1650
Enteral
feeding supply kit (syringe) (pump) (gravity), B4034–B4036
formulae, B4149–B4156, B4157–B4162
nutrition infusion pump (with alarm) (without), B9000, B9002
therapy, supplies, B4000–B9999
enteral and parenteral pumps, B9002–B9999
enteral formula/medical supplies, B0434–B4162
parenteral solutions/supplies, B4164–B5200
Epinephrine, J0171, J0173 ◀
Epirubicin HCl, J9178
Epoetin alpha, J0885, Q4081
Epoetin alpha-epbx, Retacrit (for ESRD on dialysis), Q5105
Epoetin alpha-epbx, Retacrit (non-ESRD use), Q5106
Epoetin beta, J0887–J0888
Epoprostenol, J1325
Eptinezumab-jjmr, J3032
Equipment
decubitus, E0181–E0199
exercise, A9300, E0935, E0936
orthopedic, E0910–E0948, E1800–E8002
oxygen, E0424–E0486, E1353–E1406
pump, E0781, E0784, E0791
respiratory, E0424–E0601
safety, E0700, E0705
traction, E0830–E0900
transfer, E0705
trapeze, E0910–E0912, E0940
whirlpool, E1300, E1310
Eravacycline injection, J0122
Erection device, tension ring, L7902
Ergonovine maleate, J1330
Eribulin mesylate, J9179
Ertapenem sodium, J1335
Erythromycin lactobionate, J1364
Esketamine, nasal spray, S0013
ESRD (End-Stage Renal Disease); (see also Dialysis)
diagnosis of, M1187 ◀
machines and accessories, E1500–E1699
adjustable chair, ESRD, E1570
centrifuge, dialysis, E1500
dialysis equipment, NOS, E1699
hemodialysis, air bubble detector, replacement, E1530
hemodialysis, bath conductivity meter, E1550
hemodialysis, blood leak detector, replacement, E1560
hemodialysis, blood pump, replacement, E1620
hemodialysis equipment, delivery/installation charges, E1600
hemodialysis, heparin infusion pump, E1520
hemodialysis machine, E1590
hemodialysis, portable travel hemodialyzer system, E1635
hemodialysis, pressure alarm, E1540
hemodialysis, reverse osmosis water system, E1615
 hemodialysis, sorbent cartridges, E1636
hemodialysis, transducer protectors, E1575
hemodialysis, unipuncture control system, E1580
hemodialysis, water softening system, E1625
hemostats, E1637
peritoneal dialysis, automatic intermittent system, E1592
peritoneal dialysis clamps, E1634
peritoneal dialysis, cycler dialysis machine, E1594
peritoneal dialysis, reciprocating system, E1630
scale, E1639
wearable artificial kidney, E1632
plumbing, A4870
supplies, A4651–A4929
acetate concentrate solution, hemodialysis, A4708
acid concentrate solution, hemodialysis, A4709
activated carbon filters, hemodialysis, A4680
ammonia test strip, dialysis, A4774
automatic blood pressure monitor, A4670
bicarbonate concentrate, powder, hemodialysis, A4707
bicarbonate concentrate, solution, A4706
blood collection tube, vaccum, dialysis, A4770
blood glucose test strip, dialysis, A4772
blood pressure cuff only, A4663
blood tubing, arterial and venous, hemodialysis, A4755
blood tubing, arterial or venous, hemodialysis, A4750
chemicals/antiseptics solution, clean dialysis equipment, A4674
dialysate solution, non-dextrose, A4728
dialysate solution, peritoneal dialysis, A4720–A4726, A4760–A4766
dialyzers, hemodialysis, A4690
disposable catheter tips, peritoneal dialysis, A4860
disposable cycler set, dialysis machine, A4671
drainage extension line, dialysis, sterile, A4672
extension line easy lock connectors, dialysis, A4673
fistula cannulation set, hemodialysis, A4730
injectable anesthetic, dialysis, A4737
occult blood test strips, dialysis, A4773
peritoneal dialysis, catheter anchoring device, A4653
protamine sulfate, hemodialysis, A4802
serum clotting timetube, dialysis, A4771
shunt accessory, hemodialysis, A4740
sphygmomanometer, cuff and stethoscope, A4660
 syringes, A4657
topical anesthetic, dialysis, A4736
treated water, peritoneal dialysis, A4714
“Y set” tubing, peritoneal dialysis, A4719
Estrogen conjugated, J1410
Estrone (5, Aqueous), J1435
Etelcalcetide, J0606
Eteplirsen, J1428
Ethanolamine oleate, J1430
Etidronate disodium, J1436
Etonogestrel implant system, J7307
Etoposide, J9181
oral, J8560
Euflexxa, J7323
Evaluation
conformity, V5020
contact lens, S0592
dental, D0120–D0180
diabetic, G0245, G0246
footwear, G8410–G8416
hearing, S0618, V5008, V5010
hospice, G0337
multidisciplinary, H2000
nursing, T1001
ocularist, S9150
performance measurement, S3005
resident, T2011
speech, S9152
team, T1024
Everolimus, J7527
Evinacumab-dgnb J1305
Examination
gynecological, S0610–S0613
ophthalmological, S0620, S0621
oral, D0120–D0160
pinworm, Q0113
Excision ◀
cervical nodes, C7503 ◀
neuroma, C7551 ◀
Exercise
class, S9451
 equipment, A9300
External
ambulatory infusion pump, E0781, E0784
ambulatory infusion pump continuous glucose sensing, E0787
ambulatory insulin delivery system, A9274
power, battery components, L7360–L7368
power, elbow, L7160–L7191
urinary supplies, A4356–A4359
Extractions; (see also Dental procedures), D7111–D7140, D7251
Extremity
belt/harness, E0945
traction, E0870–E0880
Eye
case, V2756
functions, documentation, G8315–G8333
lens (contact) (spectacle), V2100–V2615
pad, patch, A6410–A6412
prosthetic, V2623, V2629
service (miscellaneous), V2700–V2799
stent, S1091

F
Face tent, oxygen, A4619
Faceplate, ostomy, A4361
Facility services, dental, G0330 ◀
Factor IX, J7193, J7194, J7195, J7200–J7202
Factor VIIA coagulation factor, recombinant, J7189, J7205, J7212
Factor VIII, anti-hemophilic factor, J7182, J7185, J7190–J7192, J7207–J7209
Factor X, J7175
Factor XIII, anti-hemophilic factor, J7180, J7188
Factor XIII, A-subunit, J7181
Family Planning Education, H1010
Faricimab-svoa, J2777 ◀
Fee
coordinated care, G9001–G9011
dispensing, pharmacy, G0333, Q0510–Q0514, S9430
Fentanyl citrate, J3010
and droperidol, J1810
Fern test, Q0114
Ferric derisomaltose, J1437
Ferric pyrophosphate citrate powder, J1444
Ferumoxytol, Q0138, Q0139
Filgrastim (G-CSF &amp; TBO), J1442, J1447, Q5101
Filler, wound
alginate dressing, A6199
foam dressing, A6215
hydrocolloid dressing, A6240, A6241
hydrogel dressing, A6248
not elsewhere classified, A6261, A6262
Film, transparent (for dressing), A6257–A6259
Filter
aerosol compressor, A7014
dialysis carbon, A4680
ostomy, A4368
tracheostoma, A4481
ultrasonic generator, A7014
Fistula cannulation set, A4730
Flebogamma, J1572
Florbetapir F18, A9586
Flortaucipir, A9601 ◀
Flowmeter, E0440, E0555, E0580
Floxuridine, J9200
Fluconazole, injection, J1450
Fludarabine phosphate, J8562, J9185
Fluid barrier, dialysis, E1575
Fluid flow, Q4206
Flunisolide inhalation solution, J7641
Fluocinolone, J7311, J7313
(Yutiq), J7314
Fluoride treatment, D1201–D1205
Fluorodeoxyglucose F-18 FDG, A9552
Fluorodopa, A9602 ◀
Fluoroestradiol F 18, A9591
Fluorouracil, J9190
Fluphenazine decanoate, J2680
Foam
dressing, A6209–A6215
pad adhesive, A5126
Folding walker, E0135, E0143
Foley catheter, A4312–A4316, A4338–A4346
 indwelling catheter, specialty type, A4340
indwelling catheter, three-way, continuous irrigation, A4346
indwelling catheter, two-way, all silicone, A4344
indwelling catheter, two-way latex, A4338
insertion tray with drainage bag, A4312
insertion tray with drainage bag, three-way, continuous irrigation, A4316
insertion tray with drainage bag, two-way latex, A4314
insertion tray with drainage bag, two-way, silicone, A4315
insertion tray without drainage bag, A4313
Fomepizole, J1451
Fomivirsen sodium intraocular, J1452
Fondaparinux sodium, J1652
Foot care, G0247
Footdrop splint, L4398
Footplate, E0175, E0970, L3031
Footwear, orthopedic, L3201–L3265
additional charge for split size, L3257
Benesch boot, pair, child, L3213
Benesch boot, pair, infant, L3212
Benesch boot, pair, junior, L3214
custom molded shoe, prosthetic shoe, L3250
custom shoe, depth inlay, L3230
ladies’ shoe, depth inlay, L3216
ladies’ shoe, hightop, L3217
ladies’ shoe, oxford, L3215
ladies’ shoe, oxford/brace, L3224
men’s shoe, depth inlay, L3221
men’s shoe, hightop, L3222
men’s shoe, oxford, L3219
men’s shoe, oxford/brace, L3225
molded shoe, custom fitted, Plastazote, L3253
non-standard size or length, L3255
non-standard size or width, L3254
Plastazote sandal, L3265
shoe, hightop, child, L3206
shoe, hightop, infant, L3204
shoe, hightop, junior, L3207
shoe molded/patient model, Plastazote, L3252
shoe, molded/patient model, silicone, L3251
shoe, oxford, child, L3202
shoe, oxford, infant, L3201
 shoe, oxford, junior, L3203
surgical boot, child, L3209
surgical boot, infant, L3208
surgical boot, junior, L3211
surgical boot/shoe, L3260
Forearm crutches, E0110, E0111
Formoterol, J7640
fumarate, J7606
Fosaprepitant, J1453, J1456 ◀
Foscarnet sodium, J1455
Fosphenytoin, Q2009
Fracture
bedpan, E0276
frame, E0920, E0930, E0946–E0948
attached to bed/weights, E0920
attachments for complex cervical traction, E0948
attachments for complex pelvic traction, E0947
dual, cross bars, attached to bed, E0946
free standing/weights, E0930
orthosis, L2106–L2136, L3980–L3984
ankle/foot orthosis, fracture, L2106–L2128
KAFO, fracture orthosis, L2132–L2136
upper extremity, fracture orthosis, L3980–L3984
orthotic additions, L2180–L2192, L3995
addition to upper extremity orthosis, sock, fracture, L3995
additions lower extremity fracture, L2180–L2192
Fragmin, (see Dalteparin sodium), J1645
Frames (spectacles), V2020, V2025
deluxe frame, V2025
purchases, V2020
Fremanezumab-vfrm, J3031
Fulvestrant, J9393–J9395 ◀
Furosemide, J1940
Fusion ◀
finger joints, C7506 ◀

G
Gadobutrol, A9585
Gadofosveset trisodium, A9583
Gadoxetate disodium, A9581
Gait trainer, E8000–E8002
Gallium Ga67, A9556
Gallium illuccix, A9596 ◀
Gallium locametz, A9800 ◀
Gallium nitrate, J1457
Galsulfase, J1458
Gamma globulin, J1460, J1560
injection, gamma globulin (IM), 1cc, J1460
injection, gamma globulin (IM), over 10cc, J1560
Gammagard liquid, J1569
Gammaplex, J1557
Gamunex, J1561
Ganciclovir
implant, J7310
sodium, J1570, J1574 ◀
Garamycin, J1580
Gas system
compressed, E0424, E0425
gaseous, E0430, E0431, E0441, E0443
liquid, E0434–E0440, E0442, E0444
Gastric freezing, hypothermia, M0100
Gatifloxacin, J1590
Gauze
impregnated, A6222–A6233, A6266
non-impregnated, A6402–A6404
Gefitinib, J8565
Gel
conductive, A4558
pressure pad, E0185, E0196
Gemcitabine HCl, not otherwise specified, J9201
Infugem, J9198
Gemtuzumab ozogamicin, J9203
Generator
neurostimulator (implantable), high frequency, C1822
neurostimulator (implantable), non-rechargeable, C1827 ◀
neurostimulator (implantable), rechargeable, C1826 ◀
ultrasonic with nebulizer, E0574–E0575
Gentamicin (Sulfate), J1580
Gingival procedures, D4210–D4240
gingival flap procedure, D4240–D4241
 gingivectomy or gingivoplasty, D4210–D4212
Glasses
air conduction, V5070
binaural, V5120–V5150
behind the ear, V5140
body, V5120
glasses, V5150
in the ear, V5130
bone conduction, V5080
frames, V2020, V2025
hearing aid, V5230
Glaucoma
screening, G0117, G0118
Gloves, A4927
Glucagon HCl, J1610, J1611 ◀
Glucose
monitor includes all supplies, K0553 ✖
monitor with integrated lancing/blood sample collection, E2101
monitor with integrated voice synthesizer, E2100
receiver (monitor) dedicated, K0554 ✖
test strips, A4253, A4772
Gluteal pad, L2650
Glycopyrrolate, inhalation solution, concentrated, J7642
Glycopyrrolate, inhalation solution, unit dose, J7643
Gold
foil dental restoration, D2410–D2430
gold foil, one surface, D2410
gold foil, two surfaces, D2420
gold foil, three surfaces, D2430
sodium thiomalate, J1600
Golimumab, J1602
Gomco drain bottle, A4912
Gonadorelin HCl, J1620
Goserelin acetate implant; (see also Implant), J9202
Grab bar, trapeze, E0910, E0940
Grade-aid, wheelchair, E0974
Gradient, compression stockings, A6530–A6549
below knee, 18–30 mmHg, A6530
below knee, 30–40 mmHg, A6531
below knee, thigh length, 18–30 mmHg, A6533
full length/chap style, 18–30 mmHg, A6536
 full length/chap style, 30–40 mmHg, A6537
full length/chap style, 40–50 mmHg, A6538
garter belt, A6544
non-elastic below knee, 30–50 mmhg, A6545
sleeve, NOS, A6549
thigh length, 30–40 mmHg, A6534
thigh length, 40–50 mmHg, A6535
waist length, 18–30 mmHg, A6539
waist length, 30–40 mmHg, A6540
waist length, 40–50 mmHg, A6541
Granisetron HCl, J1626
XR, J1627
Gravity traction device, E0941
Gravlee jet washer, A4470
Guidelines, practice, oncology, G9056–G9062

H
Habilitation, prevocational, waiver, T2047
Hair analysis (excluding arsenic), P2031
Halaven, Injection, eribulin mesylate, 0.1 mg, J9179
Hallus-Valgus dynamic splint, L3100
Hallux prosthetic implant, L8642
Halo procedures, L0810–L0860
addition HALO procedure, MRI compatible systems, L0859
addition HALO procedure, replacement liner, L0861
cervical halo/jacket vest, L0810
cervical halo/Milwaukee type orthosis, L0830
cervical halo/plaster body jacket, L0820
Haloperidol, J1630
decanoate, J1631
Halter, cervical head, E0942
Hand finger orthosis, prefabricated, L3923
Hand restoration, L6900–L6915
orthosis (WHFO), E1805, E1825, L3800–L3805, L3900–L3954
partial prosthesis, L6000–L6020
partial hand, little and/or ring finger remaining, L6010
partial hand, no finger, L6020
partial hand, thumb remaining, L6000
transcarpal/metacarpal or partial hand disarticulation prosthesis, L6025
rims, wheelchair, E0967
Handgrip (cane, crutch, walker), A4636
Harness, E0942, E0944, E0945
Headgear (for positive airway pressure device), K0185
Hearing
aid, V5030–V5267, V5298
aid-body worn, V5100
assistive listening device, V5268–V5274, V5281–V5290
battery, use in hearing device, V5266
contralateral routing, V5171–V5172, V5181, V5211–V5115, V5221
dispensing fee, binaural, V5160
dispensing fee, monaural hearing aid, any type, V5241
dispensing fee, unspecified hearing aid, V5090
ear impression, each, V5275
ear mold/insert, disposable, any type, V5265
ear mold/insert, not disposable, V5264
glasses, air conduction, V5070
glasses, bone conduction, V5080
hearing aid, analog, binaural, CIC, V5248
hearing aid, analog, binaural, ITC, V5249
hearing aid, analog, monaural, CIC, V5242
hearing aid, analog, monaural, ITC, V5243
hearing aid, BICROS, V5210–V5240
hearing aid, binaural, V5120–V5150
hearing aid, CROS, V5170–V5200
hearing aid, digital, V5254–V5261
hearing aid, digitally programmable, V5244–V5247, V5250–V5253
hearing aid, disposable, any type, binaural, V5263
hearing aid, disposable, any type, monaural, V5262
hearing aid, monaural, V5030–V5060
hearing aid, NOC, V5298
hearing aid or assistive listening device/supplies/accessories, NOS, V5267
hearing service, miscellaneous, V5299
semi-implantable, middle ear, V5095
assessment, S0618, V5008, V5010
devices, L8614, V5000–V5169, V5171–V5179, V5181–V5209, V5211–V5219,
V5221–V5299
services, V5000–V5999
Heat
application, E0200–E0239
infrared heating pad system, A4639, E0221
lamp, E0200, E0205
 pad, A9273, E0210, E0215, E0237, E0249
Heater (nebulizer), E1372
Heavy duty, wheelchair, E1280–E1298, K0006, K0007, K0801–K0886
detachable arms, elevating legrests, E1280
detachable arms, swing away detachable footrest, E1290
extra heavy duty wheelchair, K0007
fixed full length arms, elevating legrest, E1295
fixed full length arms, swing away detachable footrest, E1285
heavy duty wheelchair, K0006
power mobility device, not coded by DME PDAC or no criteria, K0900
power operated vehicle, group 2, K0806–K0808
power operated vehicle, NOC, K0812
power wheelchair, group 1, K0813–K0816
power wheelchair, group 2, K0820–K0843
power wheelchair, group 3, K0848–K0864
power wheelchair, group 4, K0868–K0886
power wheelchair, group 5, pediatric, K0890–K0891
power wheelchair, NOC, K0898
power-operated vehicle, group 1, K0800–K0802
special wheelchair seat depth and/or width, by construction, E1298
special wheelchair seat depth, by upholstery, E1297
special wheelchair seat height from floor, E1296
Heel
elevator, air, E0370
protector, E0191
shoe, L3430–L3485
stabilizer, L3170
Helicopter, ambulance; (see also Ambulance)
Helmet
cervical, L0100, L0110
head, A8000–A8004
Hemin, J1640
Hemipelvectomy prosthesis, L5280
Hemi-wheelchair, E1083–E1086
Hemodialysis machine, E1590
Hemodialyzer, portable, E1635
Hemofil M, J7190
Hemophilia clotting factor, J7190–J7198
anti-inhibitor, per IU, J7198
anti-thrombin III, human, per IU, J7197
Factor IX, complex, per IU, J7194
 Factor IX, purified, non-recombinant, per IU, J7193
Factor IX, recombinant, J7195
Factor VIII, human, per IU, J7190
Factor VIII, porcine, per IU, J7191
Factor VIII, recombinant, per IU, NOS, J7192
injection, antithrombin recombinant, 50 i.u., J7196
NOC, J7199
Hemostats, A4850, E1637
Hemostix, A4773
Hepagam B
IM, J1571
IV, J1573
Heparin
infusion pump, dialysis, E1520
lock flush, J1642
sodium, J1643, J1644 ◀
Hepatitis B, vaccine, administration, G0010
Hep-Lock (U/P), J1642
Hexalite, A4590
High osmolar contrast material, Q9958–Q9964
HOCM, 400 or greater mg/ml iodine, Q9964
HOCM, 150–199 mg/ml iodine, Q9959
HOCM, 200–249 mg/ml iodine, Q9960
HOCM, 250–299 mg/ml iodine, Q9961
HOCM, 300–349 mg/ml iodine, Q9962
HOCM, 350–399 mg/ml iodine, Q9963
HOCM, up to 149 mg/ml iodine, Q9958
Hip
disarticulation prosthesis, L5250, L5270
orthosis (HO), L1600–L1690
Hip-knee-ankle-foot orthosis (HKAFO), L2040–L2090
Histrelin
acetate, J1675
implant, J9225
HKAFO, L2040–L2090
Home
certification, home health, G0180
glucose, monitor, E0607, E2100, E2101, S1030, S1031
health, aide, G0156, S9122, T1021
health, aide, in home, per hour, S9122
health, aide, per visit, T1021
 health, clinical, social worker, G0155
health, data collection, G0322 ◀
health, hospice, each 15 min, G0156
health, occupational, therapist, G0152
health, physical therapist, G0151
health, physician, certification, G0179–G0182
health, respiratory therapy, S5180, S5181
recertification, home health, G0179
supervision, home health, G0181
supervision, hospice, G0182
therapist, speech, S9128
Home Health Agency Services, T0221, T1022
care improvement home visit assessment, G9187
Home sleep study test, G0398–G0400
HOPPS, C1000–C9999
Hospice care
assisted living facility, Q5002
hospice facility, Q5010
inpatient hospice facility, Q5006
inpatient hospital, Q5005
inpatient psychiatric facility, Q5008
long-term care facility, Q5007
nursing long-term facility, Q5003
patient’s home, Q5001
services, M1154, M1159, M1186 ◀
skilled nursing facility, Q5004
Hospice, evaluation, pre-election, G0337
Hospice physician supervision, G0182
Hospital
bed, E0250–E0304, E0328, E0329
observation, G0378, G0379
outpatient clinic visit, assessment, G0463
Hospital Outpatient Payment System, C1000–C9999
Hot water bottle, A9273
Human fibrinogen concentrate, J7178
Humidifier, A7046, E0550–E0563
durable, diring IPPB treatment, E0560
durable, extensive, IPPB, E0550
durable glass bottle type, for regulator, E0555
heated, used with positive airway pressure device, E0562
non-heated, used with positive airway pressure, E0561
 water chamber, humidifier, replacement, positive airway device, A7046
Hyalgan, J7321
Hyalomatrix, Q4117
Hyaluronan, J7326, J7327
derivative, J7332
durolane, J7318
gel-Syn, J7328
genvisc, J7320
hymovis, J7322
trivisc, J7329
Hyaluronate, sodium, J7317
Hyaluronidase, J3470, J9316
ovine, J3471–J3473
Hydralazine HCl, J0360
Hydraulic patient lift, E0630
Hydrocollator, E0225, E0239
Hydrocolloid dressing, A6234–A6241
Hydrocortisone
acetate, J1700
sodium phosphate, J1710
sodium succinate, J1720
Hydrogel dressing, A6231–A6233, A6242–A6248
Hydromorphone, J1170
Hydroxyprogesterone caproate, J1725–J1726, J1729
Hydroxyzine HCl, J3410
Hygienic item or device, disposable or non-disposable, any type, each, A9286
Hylan G-F 20, J7322
Hyoscyamine Sulfate, J1980
Hyperbaric oxygen chamber, topical, A4575
Hypertonic saline solution, J7130, J7131

I
Ibandronate sodium, J1740
Ibuprofen, J1741
Ibutilide Fumarate, J1742
Icatibant, J1744
Ice
cap, E0230
collar, E0230
Idarubicin HCl, J9211
Idursulfase, J1743
Ifosfamide, J9208
Iliac, artery, angiography, G0278
Iloprost, Q4074
Imaging, PET, G0219, G0235
any site, NOS, G0235
whole body, melanoma, non-covered indications, G0219
Imiglucerase, J1786
Immune globulin, J1575
Bivigam, 500 mg, J1556
Cuvitru, J1555
Flebogamma, J1572
Gammagard liquid, J1569
Gammaplex, J1557
Gamunex, J1561
HepaGam B, J1571
Hizentra, J1559
Intravenous services, supplies and accessories, Q2052
NOS, J1566
Octagam, J1568
Privigen, J1459
Rho(D), J2788, J2790, J2791
Rhophylac, J2791
Subcutaneous, J1562
Xembify, J1558
Immunization counseling, G0310–G0315 ◀
Immunosuppressive drug, not otherwise classified, J7599
Implant
access system, A4301
aqueous shunt, L8612
bimatoprost, intracameral implant, J7351
breast, L8600
buprenorphine implant, J0570
cochlear, L8614, L8619
collagen, urinary tract, L8603
dental, D3460, D5925, D6010–D6067, D6075–D6199
crown, provisional, D6085
endodontic endosseous implant, D3460
facial augmentation implant prosthesis, D5925
implant supported prosthetics, D6055–D6067, D6075–D6077
other implant services, D6080–D6199
 surgical placement, D6010–D6051
dextranomer/hyaluronic acid copolymer, L8604
ganciclovir, J7310
hallux, L8642
infusion pump, programmable, E0783, E0786
implantable, programmable, E0783
implantable, programmable, replacement, E0786
joint, L8630, L8641, L8658
interphalangeal joint spacer, silicone or equal, L8658
metacarpophalangeal joint implant, L8630
metatarsal joint implant, L8641
lacrimal duct, A4262, A4263
maintenance procedures, D6080
maxillofacial, D5913–D5937
auricular prosthesis, D5914
auricular prosthesis, replacement, D5927
cranial prosthesis, D5924
facial augmentation implant prosthesis, D5925
facial prosthesis, D5919
facial prosthesis, replacement, D5929
mandibular resection prosthesis, with guide flange, D5934
mandibular resection prosthesis, without guide flange, D5935
nasal prosthesis, D5913
nasal prosthesis, replacement, D5926
nasal septal prosthesis, D5922
obturator prosthesis, definitive, D5932
obturator prosthesis, modification, D5933
obturator prosthesis, surgical, D5931
obturator/prosthesis, interim, D5936
ocular prosthesis, D5916
ocular prosthesis, interim, D5923
orbital prosthesis, D5915
orbital prosthesis, replacement, D5928
trismus appliance, not for TM treatment, D5937
metacarpophalangeal joint, L8630
metatarsal joint, L8641
neurostimulator pulse generator, L8679, L8681–L8688
not otherwise specified, L8699
ocular, L8610
ossicular, L8613
osteogenesis stimulator, E0749
 percutaneous access system, A4301
removal, dental, D6100
repair, dental, D6090
replacement implantable intraspinal catheter, E0785
sinuva, J7402
synthetic, urinary, L8606
urinary tract, L8603, L8606
vascular graft, L8670
Implantable radiation dosimeter, A4650
Impregnated gauze dressing, A6222–A6230, A6231–A6233
Inclisiran, J1306 ◀
Incobotulinumtoxin a, J0588
Incontinence
appliances and supplies, A4310, A4331, A4332, A4360, A5071–A5075, A5081–A5093,
A5102–A5114
garment, A4520, T4521–T4543
adult sized disposable incontinence product, T4522–T4528
any type, e.g. brief, diaper, A4520
pediatric sized disposable incontinence product, T4529–T4532
youth sized disposable incontinence product, T4533–T4534
supply, A4335, A4356–A4360
bedside drainage bag, A4357
disposable external urethral clamp/compression device, A4360
external urethral clamp or compression device, A4356
incontinence supply, miscellaneous, A4335
urinary drainage bag, leg or abdomen, A4358
treatment system, E0740
Indium IN-111
carpromab pendetide, A9507
ibritumomab tiuxetan, A9542
labeled autologous platelets, A9571
labeled autologous white blood cells, A9570
oxyquinoline, A9547
pentetate, A9548
pentetreotide, A9572
satumomab, A4642
Index visit, M1196, M1204 ◀
Inebilizumab-cdon, J1823
Infliximab injection, J1745
Influenza
afluria, Q2035
 agriflu, Q2034
flulaval, Q2036
fluvirin, Q2037
fluzone, Q2038
immunization, documentation, G8482–G8484
not otherwise specified, Q2039
vaccine, administration, G0008
virus vaccine, Q2034–Q2039
Infusion
covid, M0249, M0250
pump, ambulatory, with administrative equipment, E0781
pump, continuous glucose sensing supplies for maintenance, A4226
pump, heparin, dialysis, E1520
pump, implantable, E0782, E0783
pump, implantable, refill kit, A4220
pump, insulin, E0784
pump, mechanical, reusable, E0779, E0780
pump, uninterrupted infusion of Epiprostenol, K0455
replacement battery, A4602
saline, J7030–J7060
supplies, A4219, A4221, A4222, A4225, A4230–A4232, E0776–E0791
therapy, other than chemotherapeutic drugs, Q0081, Q2054
Inhalation solution; (see also drug name), J7608–J7699, Q4074
Injection device, needle-free, A4210
Injections; (see also drug name), J0120–J2504, J0223, J0224, J0591, J0691, J0693, J0699,
J0741, J0742, J0791, J0896, J1201, J1303, J1305, J1426, J1427, J1429, J1445, J1448,
J1554, J1823, J1942–J1944, J2406, J2506, J2794, J2798, J3031, J3399, J7169, J7204,
J7208, J7311, J7313, J7314, J7320, J7321, J7332, J9032, J9036, J9037, J9039, J9044,✖
J9057, J9118, J9153, J9173, J9177, J9199, J9201, J9210, J9223, J9229, J9247, J9269,
J9271, J9272, J9299, J9308, J9309, J9313, J9314, J9316, J9317, J9348, J9349, J9353,
J9355, J9356, Q0244, Q0249, Q5112–Q5118, Q5122, Q5123, Q9950, Q9991, Q9992
ado-trastuzumab emtansine, 1 mg, J9354
aripiprazole, extended release, J0401
arthrography, sacroiliac, joint, G0259, G0260
carfilzomib, 1 mg, J9047
certolizumab pegol, J0717
dental service, D9610, D9630
other drugs/medicaments, by report, D9630
therapeutic parenteral drug, single administration, D9610
therapeutic parenteral drugs, two or more administrations, different medications,
D9612
 dermal filler (LDS), G0429
filgrastim, J1442
interferon beta-1a, IM, Q3027
interferon beta-1a, SC, Q3028
omacetaxtine mepesuccinate, 0.01 mg, J9262
pertuzumb, 1 mg, J9306
sculptra, 0.5 mg, Q2028
supplies for self-administered, A4211
vincristine, 1 mg, J9371
ziv-aflibercept, 1 mg, J9400
Inlay/onlay dental restoration, D2510–D2664
INR, monitoring, G0248–G0250
demonstration prior to initiation, home INR, G0248
physician review and interpretation, home INR, G0250
provision of test materials, home INR, G0249
Insertion tray, A4310–A4316
Instillation, hexaminolevulinate hydrochloride, A9589
Insulin, J1815, J1817, S5550–S5571
ambulatory, external, system, A9274
treatment, outpatient, G9147
Integra flowable wound matrix, Q4114
Interferon
Alpha, J9212–J9215
Beta-1a, J1826, Q3027, Q3028
Beta-1b, J1830
Gamma, J9216
Intermittent
assist device with continuous positive airway pressure device, E0470–E0472
limb compression device, E0676
peritoneal dialysis system, E1592
positive pressure breathing machine (IPPB), E0500
Interphalangeal joint, prosthetic implant, L8658, L8659
Interscapular thoracic prosthesis
endoskeletal, L6570
upper limb, L6350–L6370
Intervention, alcohol/substance (not tobacco), G0396–G0397
Intervention, tobacco, G9016
Intraconazole, J1835
Intraocular
lenses, V2630–V2632
Intraoral radiographs, dental, D0210–D0240
 intraoral-complete series, D0210
intraoral-occlusal image, D0420
intraoral-periapical-each additional image, D0230
intraoral-periapical-first radiographic image, D0220
Intrapulmonary percussive ventilation system, E0481
Intrauterine copper contraceptive, J7300
Inversion/eversion correction device, A9285
Iodine I-123
iobenguane, A9582
ioflupane, A9584
sodium iodide, A9509, A9516
Iodine I-125
serum albumin, A9532
sodium iodide, A9527
sodium iothalamate, A9554
Iodine I-131
iodinated serum albumin, A9524
sodium iodide capsule, A9517, A9528
sodium iodide solution, A9529–A9531
Iodine Iobenguane sulfate I-131, A9508
Iodine swabs/wipes, A4247
IPD
system, E1592
Ipilimumab, J9228
IPPB machine, E0500
Ipratropium bromide, inhalation solution, unit dose, J7644, J7645
Irinotecan, J9205, J9206
Iron
Dextran, J1750
sucrose, J1756
Irrigation solution for bladder calculi, Q2004
Irrigation supplies, A4320–A4322, A4355, A4397–A4400
irrigation supply, sleeve, each, A4397
irrigation syringe, bulb, or piston, each, A4320
irrigation tubing set, bladder irrigation, A4355
ostomy irrigation set, A4400
ostomy irrigation supply, bag, A4398
ostomy irrigation supply, cone/catheter, A4399
Irrigation/evacuation system, bowel
control unit, E0350
disposable supplies for, E0352
 manual pump enema, A4459
tubing, K1013
Isatuximab-irfc, J9227
Isavuconazonium, J1833
Islet, transplant, G0341–G0343, S2102
Isoetharine HCl, inhalation solution
concentrated, J7647, J7648
unit dose, J7649, J7650
Isolates, B4150, B4152
Isoproterenol HCl, inhalation solution
concentrated, J7657, J7658
unit dose, J7659, J7660
Isosulfan blue, Q9968
Item, non-covered, A9270
IUD, J7300, S4989
IV pole, each, E0776, K0105
Ixabepilone, J9207

J
Jacket
scoliosis, L1300, L1310
Jaw, motion, rehabilitation system, E1700–E1702
Jemperli, J9272
Jenamicin, J1580
Jetria, (ocriplasmin), J7316

K
Kadcyla, ado-trastuzumab emtansine, 1 mg, J9354
Kanamycin sulfate, J1840, J1850
Kartop patient lift, toilet or bathroom; (see also Lift), E0625
Keramatrix or kerasorb, J4165
Ketorolac thomethamine, J1885
Kidney
diagnosis of CKD stage 5, M1188 ◀
ESRD supply, A4650–A4927
machine, E1500–E1699
machine, accessories, E1500–E1699
system, E1510
 wearable artificial, E1632
Kits
enteral feeding supply (syringe) (pump) (gravity), B4034–B4036
fistula cannulation (set), A4730
parenteral nutrition, B4220–B4224
administration kit, per day, B4224
supply kit, home mix, per day, B4222
supply kit, premix, per day, B4220
surgical dressing (tray), A4550
tracheostomy, A4625
Knee
arthroscopy, surgical, G0289, S2112, S2300
knee, surgical, harvesting cartilage, S2112
knee, surgical, removal loose body, chondroplasty, different compartment, G0289
shoulder, surgical, thermally-induced, capsulorraphy, S2300
disarticulation, prosthesis, L5150, L5160
joint, miniature, L5826
orthosis (KO), E1810, L1800–L1885, K1014
dynamic adjustable elbow entension/flexion device, E1800
dynamic adjustable knee extension/flexion device, E1810
static-progressive devices, E1801, E1806, E1811, E1816–E1818, E1831, E1841
Knee-ankle-foot device with microprocessor control, L2006
Knee-ankle-foot orthosis (KAFO), K1007, L2000–L2039, L2126–L2136
addition, high strength, lightweight material, L2755
base procedure, used with any knee joint, double upright, double bar, L2020
base procedure, used with any knee joint, full plastic double upright, L2036
base procedure, used with any knee joint, single upright, single bar, L2000
foot orthrosis, double upright, double bar, without knee joint, L2030
foot orthrosis, single upright, single bar, without knee joint, L2010
Kovaltry, J7211
Kyphosis pad, L1020, L1025

L
Laboratory
dental, D0415–D0999
adjunctive pre-diagnostic tests, mucosal abnormalities, D0431
analysis saliva sample, D0418
caries risk assessment, low, D0601
caries risk assessment, moderate, D0602
caries susceptibility tests, D0425
 collection and preparation, saliva sample, D0417
collection of microorganisms for culture and sensitivity, D0415
diagnostic casts, D0470
oral pathology laboratory, D0472–D0502
processing, D0414
pulp vitality tests, D0460
services, P0000–P9999
viral culture, D0416
Laboratory tests
chemistry, P2028–P2038
cephalin flocculation, blood, P2028
congo red, blood, P2029
hair analysis, excluding arsenic, P2031
mucoprotein, blood, P2038
thymol turbidity, blood, P2033
microbiology, P7001
miscellaneous, P9010–P9615, Q0111–Q0115
blood, split unit, P9011
blood, whole, transfusion, unit, P9010
catheterization, collection specimen, multiple patients, P9615
catheterization, collection specimen, single patient, P9612
cryoprecipitate, each unit, P9012
fern test, Q0114
fresh frozen plasma, donor retested, each unit, P9060
fresh frozen plasma (single donor), frozen within 8 hours, P9017
fresh frozen plasma, within 8–24 hours of collection, each unit, P9059
granulocytes, pheresis, each unit, P9050
infusion, albumin (human), 25%, 20 ml, P9046
infusion, albumin (human), 25%, 50 ml, P9047
infusion, albumin (human), 5%, 250 ml, P9045
infusion, albumin (human), 5%, 50 ml, P9041
infusion, plasma protein fraction, human, 5%, 250 ml, P9048
infusion, plasma protein fraction, human, 5%, 50 ml, P9043
KOH preparation, Q0112
pinworm examinations, Q0113
plasma, cryoprecipitate reduced, each unit, P9044
plasma, pooled, multiple donor, frozen, P9023
platelet rich plasma, each unit, P9020
platelets, each unit, P9019
platelets, HLA-matched leukocytes reduced, apheresis/pheresis, each unit, P9052
platelets, irradiated, each unit, P9032
 platelets, leukocytes reduced, CMV-neg, aphresis/pheresis, each unit, P9055
platelets, leukocytes reduced, each unit, P9031
platelets, leukocytes reduced, irradiated, each unit, P9033
platelets, pheresis, each unit, P9034
platelets, pheresis, irradiated, each unit, P9036
platelets, pheresis, leukocytes reduced, CMV-neg, irradiated, each unit, P9053
platelets, pheresis, leukocytes reduced, each unit, P9035
platelets, pheresis, leukocytes reduced, irradiated, each unit, P9037
post-coital, direct qualitative, vaginal or cervical mucous, Q0115
red blood cells, deglycerolized, each unit, P9039
red blood cells, each unit, P9021
red blood cells, frozen/deglycerolized/washed, leukocytes reduced, irradiated, each unit,
P9057
red blood cells, irradiated, each unit, P9038
red blood cells, leukocytes reduced, CMV-neg, irradiated, each unit, P9058
red blood cells, leukocytes reduced, each unit, P9016
red blood cells, leukocytes reduced, irradiated, each unit, P9040
red blood cells, washed, each unit, P9022
travel allowance, one way, specimen collection, home/nursing home, P9603, P9604
wet mounts, vaginal, cervical, or skin, Q0111
whole blood, leukocytes reduced, irradiated, each unit, P9056
whole blood or red blood cells, leukocytes reduced, CMV-neg, each unit, P9051
whole blood or red blood cells, leukocytes reduced, frozen, deglycerol, washed, each
unit, P9054
toxicology, P3000–P3001, Q0091
Lacrimal duct, implant
permanent, A4263
temporary, A4262
Lactated Ringer’s infusion, J7120
Laetrile, J3570
Lanadelumab-flyo, J0593
Lancet, A4258, A4259
Language, screening, V5363
Lanreotide, J1930, J1932 ◀
Laronidase, J1931
Larynx, artificial, L8500
Laser blood collection device and accessory, A4257, E0620
LASIK, S0800
Lead investigation, T1029
Lead wires, per pair, A4557
Leg
 bag, A4358, A5105, A5112
leg or abdomen, vinyl, with/without tubes, straps, each, A4358
urinary drainage bag, leg bag, leg/abdomen, latex, with/without tube, straps, A5112
urinary suspensory, leg bag, with/without tube, each, A5105
extensions for walker, E0158
rest, elevating, K0195
rest, wheelchair, E0990
strap, replacement, A5113–A5114
Legg Perthes orthosis, L1700–L1755
Newington type, L1710
Patten bottom type, L1755
Scottish Rite type, L1730
Tachdjian type, L1720
Toronto type, L1700
Lens
aniseikonic, V2118, V2318
contact, V2500–V2599
gas permeable, V2510–V2513
hydrophilic, V2520–V2523
other type, V2599
PMMA, V2500–V2503
scleral, gas, V2530–V2531
eye, V2100–V2615, V2700–V2799
bifocal, glass or plastic, V2200–V2299
contact lenses, V2500–V2599
low vision aids, V2600–V2615
miscellaneous, V2700–V2799
single vision, glass or plastic, V2100–V2199
trifocal, glass or plastic, V2300–V2399
variable asphericity, V2410–V2499
intraocular, V2630–V2632
anterior chamber, V2630
iris supported, V2631
new technology, category 4, IOL, Q1004
new technology, category 5, IOL, Q1005
posterior chamber, V2632
telescopic lens, C1840
low vision, V2600–V2615
hand held vision aids, V2600
single lens spectacle mounted, V2610
telescopic and other compound lens system, V2615
 progressive, V2781
Lepirudin, J1945
Lesion, destruction, choroid, G0186
Leucovorin calcium, J0640
Leukocyte poor blood, each unit, P9016
Leuprolide acetate, J1950, J1951, J9217, J9219
for depot suspension, 7.5 mg, J9217
implant, 65 mg, J9219
injection, for depot suspension, per 3.75 mg, J1950
per 1 mg, J9218
Leuprolide injectable, camcevi, J1952 ◀
Levalbuterol, all formulations, inhalation solution
concentrated, J7607, J7612
unit dose, J7614, J7615
Levetiracetam, J1953
Levocarnitine, J1955
Levofloxacin, J1956
Levoleucovorin injection, J0641
Levoleucovorin injection (khapzory), J0642
Levonorgestrel, (contraceptive), implants and supplies, J7306
Levorphanol tartrate, J1960
Lexidronam, A9604
Lidocaine HCl, J2001
Lift
patient (includes seat lift), E0621–E0635
bathroom or toilet, E0625
mechanism incorporated into a combination liftchair, E0627
patient lift, electric, E0635
patient lift, hydraulic or mechanical, E0630
separate seat lift mechanism, patient owned furniture, non-electric, E0629
sling or seat, canvas or nylon, E0621
shoe, L3300–L3334
lift, elevation, heel, L3334
lift, elevation, heel and sole, cork, L3320
lift, elevation, heel and sole, Neoprene, L3310
lift, elevation, heel, tapered to metatarsals, L3300
lift, elevation, inside shoe, L3332
lift, elevation, metal extension, L3330
Lightweight, wheelchair, E1087–E1090, E1240–E1270
detachable arms, swing away detachable, elevating leg rests, E1240
detachable arms, swing away detachable footrest, E1260
 fixed full length arms, swing away detachable elevating legrests, E1270
fixed full length arms, swing away detachable footrest, E1250
high strength, detachable arms desk, E1088
high strength, detachable arms desk or full length, E1090
high strength, fixed full length arms, E1087
high strength, fixed length arms swing away footrest, E1089
Lincomycin HCl, J2010
Linezolid, J2020, J2021 ◀
Liquid barrier, ostomy, A4363
Listening devices, assistive, V5281–V5290
personal Bluetooth FM/DM, V5286
personal FM/DM adapter/boot coupling device for receiver, V5289
personal FM/DM binaural, 2 receivers, V5282
personal FM/DM, direct audio input, V5285
personal FM/DM, ear level receiver, V5284
personal FM/DM monaural, 1 receiver, V5281
personal FM/DM neck, loop induction receiver, V5283
personal FM/DM transmitter assistive listening device, V5288
transmitter microphone, V5290
Lodging, recipient, escort nonemergency transport, A0180, A0200
LOPS, G0245–G0247
follow-up evaluation and management, G0246
initial evaluation and management, G0245
routine foot care, G0247
Lorazepam, J2060
Loss of protective sensation, G0245–G0247
Low osmolar contrast material, Q9965–Q9967
Loxapine, for inhalation, J2062
LSO, L0621–L0640
Lubricant, A4332, A4402
Lumbar flexion, L0540
Lumbar-sacral orthosis (LSO), L0621–L0640
Lutetium, A9607 ◀
LVRS, services, G0302–G0305
Lymphocyte immune globulin, J7504, J7511
 M
Machine
IPPB, E0500
kidney, E1500–E1699
Magnesium sulphate, J3475
Maintenance contract, ESRD, A4890
Mammography, screening, G9899, G9900
Mannitol, J2150, J7665
Marker, tissue, A4648
Mask
aerosol, K0180
oxygen, A4620
Mastectomy
bra, L8000
form, L8020
prosthesis, L8030, L8600
sleeve, L8010
Matristem, Q4118
micromatrix, 1 mg, Q4118
Mattress
air pressure, E0186
alternating pressure, E0277
dry pressure, E0184
gel pressure, E0196
hospital bed, E0271, E0272
non-powered, pressure reducing, E0373
overlay, E0371–E0372
powered, pressure reducing, E0277
water pressure, E0187
Measurement period
ace inhibior, M1200, M1203 ◀
anaphylaxis, M1155 ◀
bone marrow transplant, M1157 ◀
chemotherapy, M1156 ◀
dementia, M1164 ◀
herpes zoster, M1174, M1176 ◀
hospice services, M1159, M1165, M1167, M1191 ◀
immunocompromising condition (history of), M1158 ◀
 influenza vaccine, M1168, M1170 ◀
left ventricular function testing, G8682
pneumococcal conjugate, M1179 ◀
td or tdap vaccine, M1171, M1173 ◀
Mecasermin, J2170
Mechlorethamine HCl, J9230
Medicaid, codes, T1000–T9999
Medical and surgical supplies, A4206–A8999
Medical nutritional therapy, G0270, G0271
Medical services, other, M0000–M9999
Medications, high-risk, M1209–M1210 ◀
Medroxyprogesterone acetate, J1050
Meloxicam, J1738
Melphalan flufenamide J9247
Melphalan NOS, J9245, J9246
Melphalan oral, J8600
Membrane graft/wrap, Q4205
Mental, health, training services, C7900–C7902, G0177 ◀
Meperidine, J2175
and promethazine, J2180
Mepivacaine HCl, J0670
Mepolizumab, J2182
Meropenem, J2184, J2185 ◀
Mesna, J9209
Metacarpophalangeal joint, prosthetic implant, L8630, L8631
Metaproterenol sulfate, inhalation solution
concentrated, J7667, J7668
unit dose, J7669, J7670
Metaraminol bitartrate, J0380
Metatarsal joint, prosthetic implant, L8641
Meter, bath conductivity, dialysis, E1550
Methacholine chloride, J7674
Methadone HCl, J1230
Methergine, J2210
Methocarbamol, J2800
Methotrexate
oral, J8610
sodium, J9250, J9260
Methyldopate HCl, J0210
Methylene blue, Q9968
Methylnaltrexone, J2212
Methylprednisolone
acetate, J1020–J1040
injection, 20 mg, J1020
injection, 40 mg, J1030
injection, 80 mg, J1040
oral, J7509
sodium succinate, J2920, J2930
Metoclopramide HCl, J2765
Micafungin sodium, J2247, J2248 ◀
Microbiology test, P7001
Midazolam HCl, J2250, J2251 ◀
Mileage
ALS, A0390
ambulance, A0380, A0390
Milrinone lactate, J2260
Mini-bus, nonemergency transportation, A0120
Minocycline hydrochloride, J2265
Miscellaneous and investigational, A9000–A9999
Mitomycin, J7315, J9280, J9281
Mitoxantrone HCl, J9293
MNT, G0270, G0271
Mobility device, physician, service, G0372
Modalities, with office visit, M0005–M0008
Mogamulizumab injection-kpkc, J9201
Moisture exchanger for use with invasive mechanical ventilation, A4483
Moisturizer, skin, A6250
Molecular pathology procedure, G0452
Monitor
blood glucose, home, E0607
blood pressure, A4670
pacemaker, E0610, E0615
Monitoring feature/device, A9279
Monitoring, INR, G0248–G0250
demonstration prior to initiation, G0248
physician review and interpretation, G0250
provision of test materials, G0249
Monoclonal antibodies, J7505
Morphine sulfate, J2270, J2272 ◀
epidural or intrathecal use, J2274
Motion, jaw, rehabilitation system, E1700–E1702
motion rehabilitation system, E1700
 replacement cushions, E1701
replacement measuring scales, E1702
Mouthpiece (for respiratory equipment), A4617
Moxetumomab pasudotox-tdfx, J9313
Moxifloxacin, J2280, J2281 ◀
Mucoprotein, blood, P2038
Multiaxial ankle, L5986
Multidisciplinary services, H2000–H2001, T1023–T1028
Multiple post collar, cervical, L0180–L0200
occipital/mandibular supports, adjustable, L0180
occipital/mandibular supports, adjustable cervical bars, L0200
SQMI, Guilford, Taylor types, L0190
Multi-Podus type AFO, L4396
Muromonab-CD3, J7505
Mycophenolate mofetil, J7517
Mycophenolic acid, J7518
MyOwn skin, Q4226

N
Nabilone, J8650
Nails, trimming, dystrophic, G0127
Nalbuphine HCl, J2300
Naloxone HCl, J2310, J2311 ◀
Naltrexone, J2315
Nandrolone
decanoate, J2320
Narrowing device, wheelchair, E0969
Nasal
application device, K0183
pillows/seals (for nasal application device), K0184
vaccine inhalation, J3530
Nasogastric tubing, B4081, B4082
Natalizumab, J2323
Nebulizer, E0570–E0585
aerosol compressor, E0571, E0572
aerosol mask, A7015
corrugated tubing, disposable, A7010
filter, disposable, A7013
filter, non-disposable, A7014
 heater, E1372
large volume, disposable, prefilled, A7008
large volume, disposable, unfilled, A7007
not used with oxygen, durable, glass, A7017
pneumatic, administration set, A7003, A7005, A7006
pneumatic, nonfiltered, A7004
portable, E0570
small volume, A7003–A7005
ultrasonic, E0575
ultrasonic, dome and mouthpiece, A7016
ultrasonic, reservoir bottle, non-disposable, A7009
water collection device, large volume nebulizer, A7012
Necitumumab, J9295
Needle, A4215
bone marrow biopsy, C1830
non-coring, A4212
with syringe, A4206–A4209
Negative pressure wound therapy pump, E2402
accessories, A6550
Nelarabine, J9261
Neonatal transport, ambulance, base rate, A0225
Neostigmine methylsulfate, J2710
Nerve, conduction, sensory, test, G0255
Nerve stimulator with batteries, E0765
Nesiritide injection, J2324, J2325
Neupogen, injection, filgrastim, 1 mcg, J1442
Neuromuscular stimulator, E0745
Neurophysiology, intraoperative, monitoring, G0453
Neurostimulator
battery recharging system, L8695
external antenna, L8696
implantable pulse generator, L8679
pulse generator, L8681–L8688
dual array, non-rechargeable, with extension, L8688
dual array, rechargeable, with extension, L8687
patient programmer (external), replacement only, L8681
radiofrequency receiver, L8682
radiofrequency transmitter (external), sacral root receiver, bowel and bladder
management, L8684
radiofrequency transmitter (external), with implantable receiver, L8683
single array, rechargeable, with extension, L8686
Nipple prosthesis, custom fabricated, reusable, L8033
Nipple prosthesis, prefabricated, reusable, L8032
Nitrogen N-13 ammonia, A9526
Nivol relatlimab, J9298 ◀
NMES, E0720–E0749
Nonchemotherapy drug, oral, NOS, J8499
Noncovered services, A9270
Nonemergency transportation, A0080–A0210
Nonimpregnated gauze dressing, A6216–A6221, A6402–A6404
Nonprescription drug, A9150
Not otherwise classified drug, J3490, J7599, J7699, J7799, J8499, J8999, J9999, Q0181
Novafix, Q4208
NPH, J1820
NPWT, pump, E2402
NTIOL category 3, Q1003
NTIOL category 4, Q1004
NTIOL category 5, Q1005
Nursing care, T1030–T1031
Nursing service, direct, skilled, outpatient, G0128
Nusinersen, J2326
Nutrition
counseling, dental, D1310, D1320
enteral infusion pump, B9002
parenteral infusion pump, B9004, B9006
parenteral solution, B4164–B5200
therapy, medical, G0270, G0271

O
O & P supply/accessory/service, L9900
Observation
admission, G0379
hospital, G0378
Obturator prosthesis
definitive, D5932
interim, D5936
surgical, D5931
Occipital/mandibular support, cervical, L0160
Occlusive device, placement, G0269
Occupational, therapy, G0129, S9129
Ocrelizumab, J2350
Ocriplasmin, J7316
Octafluoropropane, Q9956
Octagam, J1568
Octreotide acetate, J2353, J2354
Ocular prosthetic implant, L8610
Ofatumumab, J9302
Olanzapine, J2358
Olaratumab, J9285
Oliceridine, C9101 ◀
Omacetaxine Mepesuccinate, J9262
Omadacycline, J0121
Omalizumab, J2357
Omegaven, B4187
OnabotulinumtoxinA, J0585
Oncology
disease status, G9063–G9139
practice guidelines, G9056–G9062
visit, G9050–G9055
Ondansetron HCl, J2405
Ondansetron oral, Q0162
One arm, drive attachment, K0101
Ophthalmological examination, refraction, S0621
Oprelvekin, J2355
Oral and maxillofacial surgery, D7111–D7999
alveoloplasty, D7310–D7321
complicated suturing, D7911–D7912
excision of bone tissue, D7471–D7490
extractions, local, D7111–D7140
other repair procedures, D7920–D7999
other surgical procedures, D7260–D7295
reduction of dislocation/TMJ dysfunction, D7810–D7899
repair of traumatic wounds, D7910
surgical excision, intra-osseous lesions, D7440–D7465
surgical excision, soft tissue lesions, D7410–D7415
surgical extractions, D7210–D7251
surgical incision, D7510–D7560
treatment of fractures, compound, D7710–D7780
treatment of fractures, simple, D7610–D7680
vestibuloplasty, D7340–D7350
Oral device/appliance, E0485–E0486, K1028, K1029 ◀
Oral interface, A7047
Oral, NOS, drug, J8499
Oral/nasal mask, A7027
nasal pillows, A7029
oral cushion, A7028
Oritavancin, J2406, J2407
Oropharyngeal suction catheter, A4628
Orphenadrine, J2360
Orthodontics, D8000–D8999
Orthopedic shoes
arch support, L3040–L3100
footwear, L3000–L3649, L3201–L3265
insert, L3000–L3030
lift, L3300–L3334
miscellaneous additions, L3500–L3595
positioning device, K1015, L3140–L3170
transfer, L3600–L3649
wedge, L3340–L3420
Orthotic additions
carbon graphite lamination, L2755
fracture, L2180–L2192, L3995
halo, L0860
lower extremity, L2200–L2999, L4320
ratchet lock, L2430
scoliosis, L1010–L1120, L1210–L1290
shoe, L3300–L3595, L3649
spinal, L0970–L0984
upper limb, L3810–L3890, L3900, L3901, L3970–L3974, L3975–L3978, L3995
Orthotic devices
ankle-foot (AFO); (see also Orthopedic shoes), E1815, E1816, E1830, L1900–L1990,
L2102–L2116, L3160, L4361, L4397
anterior-posterior-lateral, L0700, L0710
cervical, L0100–L0200
cervical-thoracic-lumbar-sacral (CTLSO), L0700, L0710
elbow (EO), E1800, E1801, L3700–L3740, L3760–L3761, L3762
fracture, L2102–L2136, L3980–L3986
halo, L0810–L0830
hand, (WHFO), E1805, E1825, L3807, L3900–L3954, L3956
hand, finger, prefabricated, L3923
hip (HO), L1600–L1690
hip-knee-ankle-foot (HKAFO), L2040–L2090
 interface material, E1820
knee (KO), E1810, E1811, L1800–L1885
knee-ankle-foot (KAFO); (see also Orthopedic shoes), L2000–L2038, L2126–L2136
Legg Perthes, L1700–L1755
lumbar, L0625–L0651
multiple post collar, L0180–L0200
not otherwise specified, L0999, L1499, L2999, L3999, L5999, L7499, L8039, L8239
pneumatic splint, L4350–L4380
pronation/supination, E1818
repair or replacement, L4000–L4210
replace soft interface material, L4390–L4394
sacroiliac, L0600–L0620, L0621–L0624
scoliosis, L1000–L1499
shoe, (see Orthopedic shoes)
shoulder (SO), L1840, L3650, L3674, L3678
shoulder-elbow-wrist-hand (SEWHO), L3960–L3978
side bar disconnect, L2768
spinal, cervical, L0100–L0200
spinal, DME, K0112–K0116
thoracic, L0210, L0220
thoracic-hip-knee-ankle (THKO), L1500–L1520
toe, E1830
wrist-hand-finger (WHFO), E1805, E1806, E1825, L3806–L3809, L3900–L3954, L3956
Orthovisc, J7324
Ossicula prosthetic implant, L8613
Osteogenesis stimulator, E0747–E0749, E0760
Osteotomy, segmented or subapical, D7944
Ostomy
accessories, A5093
belt, A4396
pouches, A4416–A4435, A5056, A5057
skin barrier, A4401–A4449, A4462
supplies, A4361–A4421, A5051–A5149, A5200
Otto Bock, prosthesis, L7007
Outpatient payment system, hospital, C1000–C9999
Overdoor, traction, E0860
Oxacillin sodium, J2700
Oxaliplatin, J9263
Oxygen
ambulance, A0422
battery charger, E1357
 battery pack/cartridge, E1356
catheter, transtracheal, A7018
chamber, hyperbaric, topical, A4575
concentrator, E1390–E1391
DC power adapter, E1358
delivery system (topical), E0446
equipment, E0424–E0486, E1353–E1406
Liquid oxygen system, E0433
mask, A4620
medication supplies, A4611–A4627
rack/stand, E1355
regulator, E1352, E1353
respiratory equipment/supplies, E0424–E0480, A4611–A4627, E0481
supplies and equipment, E0425–E0444, E0455
tent, E0455
tubing, A4616
water vapor enriching system, E1405, E1406
wheeled cart, E1354
Oxymorphone HCl, J2410
Oxytetracycline HCl, J2460
Oxytocin, J2590

P
Pacemaker monitor, E0610, E0615
Pacemaker permanent insertion, C7537–C7578 ◀
Pacemaker removal, C7540 ◀
Paclitaxel, J9267
Paclitaxel protein-bound particles, J9264
Pad
correction, CTLSO, L1020–L1060
gel pressure, E0185, E0196
heat, A9273, E0210, E0215, E0217, E0238, E0249
electric heat pad, moist, E0215
electric heat pad, standard, E0210
hot water bottle, ice cap or collar, heat and/or cold wrap, A9273
pad for water circulating heat unit, replacement only, E0249
water circulating heat pad with pump, E0217
orthotic device interface, E1820
sheepskin, E0188, E0189
 water circulating cold with pump, E0218
water circulating heat unit, E0249
water circulating heat with pump, E0217
Pail, for use with commode chair, E0167
Pain assessment, G8730–G8732
Pain management, chronic, G3002–G3003 ◀
Palate, prosthetic implant, L8618
Palifermin, J2425
Paliperidone palmitate, J2426
Palonosetron, J2469, J8655
Pamidronate disodium, J2430
Pan, for use with commode chair, E0167
Panitumumab, J9303
Papanicolaou screening smear (Pap), P3000, P3001, Q0091
cervical or vaginal, up to 3 smears, by technician, P3000
cervical or vaginal, up to 3 smears, physician interpretation, P3001
obtaining, preparing and conveyance, Q0091
Papaverine HCl, J2440
Paraffin, A4265
bath unit, E0235
Parenteral nutrition
administration kit, B4224
not otherwise specified, B4185
pump, B9004, B9006
solution, B4164, B4184, B4186
compounded amino acid and carbohydrates, with electrolytes, B4189–B4199,
B5000–B5200
nutrition additives, homemix, B4216
nutrition administration kit, B4224
nutrition solution, amino acid, B4168–B4178
nutrition solution, carbohydrates, B4164, B4180
nutrition solution, per 10 grams, liquid, B4185
nutrition supply kit, homemix, B4222
supply kit, B4220, B4222
Paricalcitol, J2501
Parking fee, nonemergency transport, A0170
Partial Hospitalization, OT, G0129
Pasireotide long acting, J2502
Paste, conductive, A4558
Pathology and laboratory tests, miscellaneous, P9010–P9615
Pathology, surgical, G0416, M1193, M1195 ◀
Patient support system, E0636, M1207–M1208 ◀
Patient transfer system, E1035–E1036
Patisiran injection, J0222
Pediculosis (lice) treatment, A9180
PEFR, peak expiratory flow rate meter, A4614
Pegademase bovine, J2504
Pegaptanib, J2503
Pegaspargase, J9266
Pegfilgrastim, J2505, Q5122
Peginesatide, J0890
Pegloticase, J2507
Pelvic
belt/harness/boot, E0944
traction, E0890, E0900, E0947
Pemetrexed, J9304–J9305
Penicillin
G benzathine/G benzathine and penicillin G procaine, J0558, J0561
G potassium, J2540
G procaine, aqueous, J2510
Pentamidine isethionate, J2545, J7676
Pentastarch, 10% solution, J2513
Pentazocine HCl, J3070
Pentobarbital sodium, J2515
Pentostatin, J9268
Peramivir, J2547
Percussor, E0480
Percutaneous ◀
biliary drainage catheter, C7545 ◀
breast biopsies, C7501–C7502 ◀
vertebral augmentations, C7507–C7508 ◀
vertebroplasties, C7504–C7505 ◀
Percutaneous access system, A4301
Perflexane lipid microspheres, Q9955
Perflutren lipid microspheres, Q9957
Periapical service, D3410–D3470
apicoectomy, bicuspid, first root, D3421
apicoectomy, each additional root, D3426
apicoectomy, molar, first root, D3425
apicoectomy/periradicular surgery-anterior, D3410
biological materials, aid soft and osseous tissue regeneration/periradicular surgery,
D3431
 bone graft, per tooth, periradicular surgery, D3429
endodonic endosseous implant, D3460
guided tissue regeneration/periradicular surgery, D3432
intentional replantation, D3470
periradicular surgery without apicoectomy, D3427
retrograde filling, per root, D3430
root amputation, D3450
Periodontal procedures, D4000–D4999
Periodontics, dental, D4000–D4999
Peroneal strap, L0980
Peroxide, A4244
Perphenazine, J3310
Personal care services, T1019–T1021
home health aide or CAN, per visit, T1021
per diem, T1020
provided by home health aide or CAN, per 15 minutes, T1019
Pertuzumab, J9306, J9316
Pessary, A4561, A4562
PET, G0219, G0235, G0252
Pharmacologic therapy, G8633
Pharmacy, fee, G0333
Phenobarbital sodium, J2560
Phentolamine mesylate, J2760
Phenylephrine HCl, J2370
Phenylephrine/ketorolac ophthalmic solution, J1097
Phenytoin sodium, J1165
Phisohex solution, A4246
Photofrin, (see Porfimer sodium)
Photorefraction keratectomy, (PRK), S0810
Phototherapeutic keratectomy, (PTK), S0812
Phototherapy light, E0202
Phytonadione, J3430
Pillow, cervical, E0943
Pin retention (per tooth), D2951
Pinworm examination, Q0113
Plasma
multiple donor, pooled, frozen, P9023, P9070
single donor, fresh frozen, P9017, P9071
Plasminogen, J2998 ◀
Plastazote, L3002, L3252, L3253, L3265, L5654–L5658
addition to lower extremity socket insert, L5654
 addition to lower extremity socket insert, above knee, L5658
addition to lower extremity socket insert, below knee, L5655
addition to lower extremity socket insert, knee disarticulation, L5656
foot insert, removable, plastazote, L3002
foot, molded shoe, custom fitted, plastazote, L3253
foot, shoe molded to patient model, plastazote, L3252
plastazote sandal, L3265
Platelet, P9073, P9100
concentrate, each unit, P9019
rich plasma, each unit, P9020
Platelets, P9031–P9037, P9052–P9053, P9055
Platform attachment
forearm crutch, E0153
walker, E0154
Plazomicin injection, J0291
Plerixafor, J2562
Plicamycin, J9270
Plumbing, for home ESRD equipment, A4870
Pneumatic
appliance, E0655–E0673, L4350–L4380
compressor, E0650–E0652
splint, L4350–L4380
ventricular assist device, Q0477, Q0480–Q0505
Pneumatic nebulizer
administration set, small volume, filtered, A7006
administration set, small volume, nonfiltered, A7003
administration set, small volume, nonfiltered, nondisposable, A7005
small volume, disposable, A7004
Pneumococcal
vaccine, administration, G0009
Polatuzumab vedotin-piiq, J9309
Pontics, D6210–D6252
Porfimer sodium, J9600
Portable
equipment transfer, R0070–R0076
gaseous oxygen, K0741, K0742
hemodialyzer system, E1635
liquid oxygen system, E0433
x-ray equipment, Q0092
Positioning seat, T5001
Positive airway pressure device, accessories, A7030–A7039, E0561–E0562
Positive expiratory pressure device, E0484
Post-coital examination, Q0115
Postural drainage board, E0606
Potassium
chloride, J3480
hydroxide preparation(KOH), Q0112
Pouch
fecal collection, A4330
ostomy, A4375–A4378, A5051–A5054, A5061–A5065
urinary, A4379–A4383, A5071–A5075
Practice, guidelines, oncology, G9056–G9062
Pralatrexate, J9307
Pralidoxime chloride, J2730
Prednisolone
acetate, J2650
oral, J7510
Prednisone, J7512
Prefabricated crown, D2930–D2933
Preparation kits, dialysis, A4914
Preparatory prosthesis, L5510–L5595
chemotherapy, J8999
nonchemotherapy, J8499
Prescription digital behavioral therapy, A9291 ◀
Pressure
alarm, dialysis, E1540
pad, A4640, E0180–E0199
Pressure sensor system, C1834 ◀
Preventive dental procedures, D1000–D1999
Privigen, J1459
Procainamide HCl, J2690
Procedure
HALO, L0810–L0861
noncovered, G0293, G0294
scoliosis, L1000–L1499
Prochlorperazine, J0780
Progenamatrix, Q4222
Prolonged Service ◀
home or residence, G0318 ◀
hospital inpatient/observation, G0316 ◀
nursing facility, G0317 ◀
Prolotherapy, M0076
Promazine HCl, J2950
Promethazine
and meperdine, J2180
HCl, J2550
Propranolol HCl, J1800
Prostate, cancer, screening, G0102, G0103
Prosthesis
artificial larynx battery/accessory, L8505
auricular, D5914
breast, L8000–L8035, L8600
dental, D5911–D5960, D5999
eye, L8610, L8611, V2623–V2629
fitting, L5400–L5460, L6380–L6388
foot/ankle one piece system, L5979
hand, L6000–L6020, L6026
implants, L8600–L8690
larynx, L8500
lower extremity, L5700–L5999, L8640–L8642
mandible, L8617
maxilla, L8616
maxillofacial, provided by a non-physician, L8040–L8048
miscellaneous service, L8499
obturator, D5931–D5933, D5936
ocular, V2623–V2629
repair of, L7520, L8049
socks (shrinker, sheath, stump sock), L8400–L8485
taxes, orthotic/prosthetic/other, L9999
tracheo-esophageal, L8507–L8509
upper extremity, L6000–L6999
vacuum erection system, L7900
Prosthetic additions
lower extremity, L5610–L5999
powered upper extremity range of motion assist device, L8701–L8702
upper extremity, L6600–L7405
Prosthetic, eye, V2623
Prosthodontic procedure
fixed, D6200–D6999
removable, D5000–D5899
Prosthodontics, removable, D5110–D5899
Protamine sulfate, J2720
Protectant, skin, A6250
Protector, heel or elbow, E0191
Protein C Concentrate, J2724
Protirelin, J2725
Psychotherapy, group, partial hospitalization, G0410–G0411
Pulp capping, D3110, D3120
Pulpotomy, D3220
partial, D3222
vitality test, D0460
Pulse generator, E2120
Pump
alternating pressure pad, E0182
ambulatory infusion, E0781, E0787
ambulatory insulin, E0784
blood, dialysis, E1620
breast, E0602–E0604
enteral infusion, B9000, B9002
external infusion, E0779
heparin infusion, E1520
implantable infusion, E0782, E0783
implantable infusion, refill kit, A4220
infusion, supplies, A4226, A4230, A4232
negative pressure wound therapy, E2402
parenteral infusion, B9004, B9006
suction, portable, E0600
water circulating pad, E0236
wound, negative, pressure, E2402
Purification system, E1610, E1615
Pyridoxine HCl, J3415

Q
Quad cane, E0105
Quinupristin/dalfopristin, J2770

R
Rack/stand, oxygen, E1355
Radiesse, Q2026
Radioelements for brachytherapy, Q3001
Radiograph, dental, D0210–D0340
Radiological, supplies, A4641, A4642
Radiology service, R0070–R0076
Radiopharmaceutical diagnostic and therapeutic imaging agent, A4641, A4642,
A9500–A9699
Radiosurgery, robotic, G0339–G0340
Radiosurgery, stereotactic, G0339, G0340
Rail
bathtub, E0241, E0242, E0246
bed, E0305, E0310
toilet, E0243
Ranibizumab, J2778
Rasburicase, J2783
Ravulizumab injection-cwvz, J1303
Reaching/grabbing device, A9281
Reagent strip, A4252
Re-cement
crown, D2920
inlay, D2910
Reciprocating peritoneal dialysis system, E1630
Reclast, J3488, J3489
Reclining, wheelchair, E1014, E1050–E1070, E1100–E1110
Reconstruction, angiography, G0288
Rectal Control System for Vaginal insertion, A4563
Red blood cells, P9021, P9022
Regadenoson, J2785
Regular insulin, J1815, J1820
Regulator, oxygen, E1353
Rehabilitation
cardiac, S9472
program, H2001
psychosocial, H2017, H2018
pulmonary, S9473
system, jaw, motion, E1700–E1702
vestibular, S9476
Releuko, Q5125 ◀
Remdesivir, J0248 ◀
Removal, cerumen, G0268
Repair
contract, ESRD, A4890
durable medical equipment, E1340
maxillofacial prosthesis, L8049
 orthosis, L4000–L4130
prosthetic, L7500, L7510
Replacement
battery, A4630
pad (alternating pressure), A4640
tanks, dialysis, A4880
tip for cane, crutches, walker, A4637
underarm pad for crutches, A4635
Resin dental restoration, D2330–D2394
Reslizumab, J2786
Respiratory
DME, A7000–A7527
equipment, E0424–E0601
function, therapeutic, procedure, G0237–G0239, S5180–S5181
supplies, A4604–A4629
Restorative dental procedure, D2000–D2999
Restraint, any type, E0710
Reteplase, J2993
Revascularization, C9603–C9608
Revefenacin inhalation solution, J7677
Rho(D) immune globulin, human, J2788, J2790, J2792
Rib belt, thoracic, A4572, L0220
Rilanocept, J2793
RimabotulinumtoxinB, J0587
Ring, ostomy, A4404
Ringers lactate infusion, J7120
Risankizumab, J2327 ◀
Risk-adjusted functional status
elbow, wrist or hand, G8667–G8670
hip, G8651–G8654
lower leg, foot or ankle, G8655–G8658
lumbar spine, G8659–G8662
neck, cranium, mandible, thoracic spine, ribs, or other, G8671–G8674
shoulder, G8663–G8666
Risperidone (risperdal consta), J2794
(perseris), J2798
Rituximab, J9312
abbs (Truxina), Q5115
Robin-Aids, L6000, L6010, L6020, L6855, L6860
Rocking bed, E0462
Rolapitant, J8670
Rollabout chair, E1031
Romidepsin, J9315
Romiplostim, J2796
Romosozumab injection-aqqg, J3111
Root canal therapy, D3310–D3353
Ropivacaine HCl, J2795
Rubidium Rb-82, A9555
Rybrevant, J9061
Rylaze, J9021

S
Sacituzumab govitecan-hziy, J9317
Sacral nerve stimulation test lead, A4290
Safety equipment, E0700
vest, wheelchair, E0980
Saline
hypertonic, J7130, J7131
infusion, J7030–J7060
solution, A4216–A4218, J7030–J7050
Saliva
artificial, A9155
collection and preparation, D0417
Samarium SM 153 Lexidronamm, A9605
Sargramostim (GM-CSF), J2820
Scale, E1639
Scoliosis, L1000–L1499
additions, L1010–L1120, L1210–L1290
Screening
alcohol misuse, G0442
cancer, cervical or vaginal, G0101
colorectal, cancer, G0104–G0106, G0120–G0122, G0328
cytopathology cervical or vaginal, G0123, G0124, G0141–G0148
depression, G0444
dysphagia, documentation, V5364
enzyme immunoassay, G0432
glaucoma, G0117, G0118
infectious agent antibody detection, G0433, G0435
language, V5363
mammography, digital image, G9899, G9900
prostate, cancer, G0102, G0103
 speech, V5362
Sculptra, Q2028
Sealant
skin, A6250
tooth, D1351
Seat
attachment, walker, E0156
insert, wheelchair, E0992
lift (patient), E0621, E0627–E0629
upholstery, wheelchair, E0975, E0981
Sebelipase alfa, J2840
Secretin, J2850
Semen analysis, G0027
Semi-reclining, wheelchair, E1100, E1110
Sensitivity study, P7001
Sensory nerve conduction test, G0255
Sermorelin acetate, Q0515
Serum clotting time tube, A4771
Service
Allied Health, home health, hospice, G0151–G0161
behavioral health and/or substance abuse, H0001–H9999
doula birth worker, T1032–T1033 ◀
hearing, V5000–V5999
laboratory, P0000–P9999
mental, health, training, G0177
non-covered, A9270
physician, for mobility device, G0372
pulmonary, for LVRS, G0302–G0305
skilled, RN/LPN, home health, hospice, G0162
social, psychological, G0409–G0411
speech-language, V5336–V5364
vision, V2020–V2799
SEWHO, L3960–L3974, L3975–L3978
SEXA, G0130
Sheepskin pad, E0188, E0189
Shoes
arch support, L3040–L3100
for diabetics, A5500–A5514
insert, L3000–L3030, L3031
lift, L3300–L3334
miscellaneous additions, L3500–L3595
 orthopedic, L3201–L3265
positioning device, L3140–L3170
transfer, L3600–L3649
wedge, L3340–L3485
Shoulder
disarticulation, prosthetic, L6300–L6320, L6550
orthosis (SO), L3650–L3674
spinal, cervical, L0100–L0200
Shoulder sling, A4566
Shoulder-elbow-wrist-hand orthosis (SEWHO), L3960–L3969, L3971–L3978
Shunt accessory for dialysis, A4740
aqueous, L8612
Sigmoidoscopy, cancer screening, G0104, G0106
Siltuximab, J2860
Sincalide, J2805
Sipuleucel-T, Q2043
Sirolimus, J7520, J9331 ◀
Sitz bath, E0160–E0162
Skin
barrier, ostomy, A4362, A4363, A4369–A4373, A4385, A5120
bond or cement, ostomy, A4364
sealant, protectant, moisturizer, A6250
substitute, Q4100–Q4258
Sling, A4565
patient lift, E0621, E0630, E0635
Smear, Papanicolaou, screening, P3000, P3001, Q0091
SNCT, G0255
Social worker, clinical, home, health, G0155
Social worker, nonemergency transport, A0160
Social work/psychological services, CORF, G0409
Sock
body sock, L0984
prosthetic sock, L8417, L8420–L8435, L8470, L8480, L8485
stump sock, L8470–L8485
Sodium
chloride injection, J2912
ferric gluconate complex in sucrose, J2916
fluoride F-18, A9580
hyaluronate
Euflexxa, J7323
GELSYN-3, J7328
 Hyalgan, J7321
Orthovisc, J7324
Supartz, J7321
Synvisc and Synvisc-One, J7325
Visco-3, J7321
phosphate P32, A9563
pyrophosphate, J1443
succinate, J1720
Solution
calibrator, A4256
dialysate, A4760
elliotts b, J9175
enteral formulae, B4149–B4156, B4157–B4162
parenteral nutrition, B4164–B5200
Solvent, adhesive remover, A4455
Somatrem, J2940
Somatropin, J2941
Sorbent cartridge, ESRD, E1636
Special size, wheelchair, E1220–E1239
Specialty absorptive dressing, A6251–A6256
Spectacle lenses, V2100–V2199
Spectinomycin HCl, J3320
Speech assessment, V5362–V5364
Speech generating device, E2500–E2599, K1009
Speech, pathologist, G0153
Speech-Language pathology, services, V5336–V5364
Spherocylinder, single vision, V2100–V2114
bifocal, V2203–V2214
trifocal, V2303–V2314
Spinal orthosis
cervical, L0100–L0200
cervical-thoracic-lumbar-sacral (CTLSO), L0700, L0710
DME, K0112–K0116
halo, L0810–L0830
multiple post collar, L0180–L0200
scoliosis, L1000–L1499
torso supports, L0960
Splint, A4570, L3100, L4350–L4380
ankle, L4390–L4398
dynamic, E1800, E1805, E1810, E1815, E1825, E1830, E1840
footdrop, L4398
 supplies, miscellaneous, Q4051
Standard, wheelchair, E1130, K0001
Static progressive stretch, E1801, E1806, E1811, E1816, E1818, E1821
Status
disease, oncology, G9063–G9139
STELARA, ustekinumab, 1 mg, J3357
Stent, transcatheter, placement, C9600, C9601
Stereotactic, radiosurgery, G0339, G0340
Sterile cefuroxime sodium, J0697
Sterile water, A4216–A4217
Stimulation, electrical, non-attended, G0281–G0283
Stimulators
neuromuscular, E0744, E0745
osteogenesis, electrical, E0747–E0749
salivary reflex, E0755
stoma absorptive cover, A5083
transcutaneous, electric, nerve, A4595–A4596, E0720–E0749 ◀
ultrasound, E0760
Stockings
gradient, compression, A6530–A6549
surgical, A4490–A4510
Stoma, plug or seal, A5081
Stomach tube, B4083
Streptokinase, J2995
Streptomycin, J3000
Streptozocin, J9320
Strip, blood glucose test, A4253–A4772
urine reagent, A4250
Strontium-89 chloride, supply of, A9600
Study, bone density, G0130
Stump sock, L8470–L8485
Stylet, A4212
Substance/Alcohol, assessment, G0396, G0397, H0001, H0003, H0049
Succinylcholine chloride, J0330
Suction pump
gastric, home model, E2000
portable, E0600
respiratory, home model, E0600
Sumatriptan succinate, J3030
Supartz, J7321
Supplies
 battery, A4233–A4236, A4601, A4611–A4613, A4638
cast, A4580, A4590, Q4001–Q4051
catheters, A4300–A4306
continuous glucose monitor, A4238, A4239 ◀
contraceptive, A4267–A4269
diabetic shoes, A5500–A5513
dialysis, A4653–A4928
DME, other, A4630–A4640
dressings, A6000–A6513
enteral, therapy, B4000–B9999
incontinence, A4310–A4355, A5102–A5200
infusion, A4221, A4222, A4230–A4232, E0776–E0791
needle, A4212, A4215
needle-free device, A4210
ostomy, A4361–A4434, A5051–A5093, A5120–A5200
parenteral, therapy, B4000–B9999
radiological, A4641, A4642
refill kit, infusion pump, A4220
respiratory, A4604–A4629
self-administered injections, A4211
splint, Q4051
sterile water/saline and/or dextrose, A4216–A4218
surgical, miscellaneous, A4649
syringe, A4206–A4209, A4213, A4232
syringe with needle, A4206–A4209
urinary, external, A4356–A4360
Supply/accessory/service, A9900
Support
arch, L3040–L3090
cervical, L0100–L0200
spinal, L0960
stockings, L8100–L8239
Surederm, Q4220
Surgery, oral, D7000–D7999
Surgical
arthroscopy, knee, G0289, S2112
boot, L3208–L3211
dressing, A6196–A6406
procedure, noncovered, G0293, G0294
stocking, A4490–A4510
supplies, A4649
 tray, A4550
Surgicord, Q4218–Q4219
Surgraft, Q4209, Q4263 ◀
Susvimo, J2779 ◀
Sutimlimab-jome, J1302 ◀
Swabs, betadine or iodine, A4247
Synojoynt, J7331
Synvisc and Synvisc-One, J7325
Syringe, A4213
with needle, A4206–A4209
System
external, ambulatory insulin, A9274
rehabilitation, jaw, motion, E1700–E1702
transport, E1035–E1039

T
Tables, bed, E0274, E0315
Tacrolimus
oral, J7503, J7507, J7508
parenteral, J7525
Tagraxofusp injections-erzs, J9269
Taliglucerase, J3060
Talimogene laheroareovec, J9325
Tape, A4450–A4452
Taxi, non-emergency transportation, A0100
Team, conference, G0175, G9007, S0220, S0221
Tebentafusp-tebn, J9274 ◀
Technetium TC 99M
Arcitumomab, A9568
Bicisate, A9557
Depreotide, A9536
Disofenin, A9510
Exametazine, A9521
Exametazine labeled autologous white blood cells, A9569
Fanolesomab, A9566
Glucepatate, A9550
Labeled red blood cells, A9560
Macroaggregated albumin, A9540
Mebrofenin, A9537
 Mertiatide, A9562
Oxidronate, A9561
Pentetate, A9539, A9567
Pertechnetate, A9512
Pyrophosphate, A9538
Sestamibi, A9500
Succimer, A9551
Sulfur colloid, A9541
Teboroxime, A9501
Tetrofosmin, A9502
Tilmanocept, A9520
Tedizolid phosphate, J3090
TEEV, J0900
Telavancin, J3095
Telehealth, Q3014, G0320–G0321 ◀
Telehealth transmission, T1014
Temozolomide
injection, J9328
oral, J8700
Temporary codes, Q0000–Q9999, S0009–S9999
Temporomandibular joint, D0320, D0321
Temsirolimus, J9330
Tenecteplase, J3101
Teniposide, Q2017
TENS, A4595–A4596, E0720–E0749 ◀
Tent, oxygen, E0455
Teprotumumab-trbw, J3241
Terbutaline sulfate, J3105
inhalation solution, concentrated, J7680
inhalation solution, unit dose, J7681
Teriparatide, J3110
Terminal devices, L6700–L6895
Test
sensory, nerve, conduction, G0255
Testosterone
cypionate and estradiol cypionate, J1071
enanthate, J3121
undecanoate, J3145
Tetanus immune globulin, human, J1670
Tetracycline, J0120
Tezepelumab, J2356 ◀
Thallous Chloride TL 201, A9505
Theophylline, J2810
Therapeutic lightbox, A4634, E0203
Therapy
activity, G0176
electromagnetic, G0295, G0329
endodontic, D3222–D3330
enteral, supplies, B4000–B9999
immune checkpoint inhibitor, M1180 ◀
medical, nutritional, G0270, G0271
occupational, G0129, H5300, S9129
occupational, health, G0152
parenteral, supplies, B4000–B9999
respiratory, function, procedure, G0237–S0239, S5180, S5181
speech, home, G0153, S9128
wound, negative, pressure, pump, E2402
Theraskin, Q4121
Thermometer, A4931–A4932
dialysis, A4910
Thiamine HCl, J3411
Thiethylperazine maleate, J3280
Thiotepa, J9340
Thoracic orthosis, L0210
Thoracic-hip-knee-ankle (THKAO), L1500–L1520
Thoracic-lumbar-sacral orthosis (TLSO)
scoliosis, L1200–L1290
spinal, L0450–L0492
Thymol turbidity, blood, P2033
Thyroidectomy, C7555 ◀
Thyrotropin Alfa, J3240
Tigecycline, J3243, J3244 ◀
Tinzarparin sodium, J1655
Tip (cane, crutch, walker) replacement, A4637
Tire, wheelchair, E2211–E2225, E2381–E2395
Tirofiban, J3246
Tisagenlecleucel, Q2040
Tisotumab vedotin-TFTV, J9273 ◀
Tissue marker, A4648
Tixagev and cilgav, Q0221 ◀
TLSO, L0450–L0492, L1200–L1290
Tobacco
 intervention, G9016
Tobramycin
inhalation solution, unit dose, J7682, J7685
sulfate, J3260
Tocilizumab, J2362
Toe device, E1831
Toilet accessories, E0167–E0179, E0243, E0244, E0625
Tolazoline HCl, J2670
Toll, non emergency transport, A0170
Tomographic radiograph, dental, D0322
Topical hyperbaric oxygen chamber, A4575
Topotecan, J8705, J9351
Torsemide, J3265
Trabectedin, J9352
Tracheostoma heat moisture exchange system, A7501–A7509
Tracheostomy
care kit, A4629
filter, A4481
speaking valve, L8501
supplies, A4623, A4629, A7523–A7524
tube, A7520–A7522
Tracheotomy mask or collar, A7525–A7526
Traction
cervical, E0855, E0856
device, ambulatory, E0830
equipment, E0840–E0948
extremity, E0870–E0880
pelvic, E0890, E0900, E0947
Training
diabetes, outpatient, G0108, G0109
home health or hospice, G0162
services, mental, health, G0177
Transcutaneous electrical nerve stimulator (TENS), E0720–E0770, K1016–K1020
Transducer protector, dialysis, E1575
Transfer (shoe orthosis), L3600–L3640
Transfer system with seat, E1035
Transparent film (for dressing), A6257–A6259
Transplant
heart (history of), M1151–M1152 ◀
islet, G0341–G0343, S2102
Transport
 chair, E1035–E1039
system, E1035–E1039
x-ray, R0070–R0076
Transportation
ambulance, A0021–A0999, Q3019, Q3020
corneal tissue, V2785
EKG (portable), R0076
handicapped, A0130
non-emergency, A0080–A0210, T2001–T2005
service, including ambulance, A0021, A0999, T2006
taxi, non-emergency, A0100
toll, non-emergency, A0170
volunteer, non-emergency, A0080, A0090
x-ray (portable), R0070, R0075, R0076
Transportation services
air services, A0430, A0431, A0435, A0436
ALS disposable supplies, A0398
ALS mileage, A0390
ALS specialized service, A0392, A0394, A0396
ambulance, ALS, A0426, A0427, A0433
ambulance, outside state, Medicaid, A0021
ambulance oxygen, A0422
ambulance, waiting time, A0420
ancillary, lodging, escort, A0200
ancillary, lodging, recipient, A0180
ancillary, meals, escort, A0210
ancillary, meals, recipient, A0190
ancillary, parking fees, tolls, A0170
BLS disposable supplies, A0382
BLS mileage, A0380
BLS specialized service, A0384
emergency, neonatal, one-way, A0225
extra ambulance attendant, A0424
ground mileage, A0425
non-emergency, air travel, A0140
non-emergency, bus, A0110
non-emergency, case worker, A0160
non-emergency, mini-bus, A0120
non-emergency, no vested interest, A0080
non-emergency, taxi, A0100
non-emergency, wheelchair van, A0130
 non-emergency, with vested interest, A0090
paramedic intercept, A0432
response and treat, no transport, A0998
specialty transport, A0434
Transtracheal oxygen catheter, A7018
Trapeze bar, E0910–E0912, E0940
Trauma, response, team, G0390
Tray
insertion, A4310–A4316
irrigation, A4320
surgical; (see also kits), A4550
wheelchair, E0950
Trastuzumab injection excludes biosimilar, J9316, J9355
anns (kanjinti), Q5117
dkst (Ogivri), Q5114
dttb (Ontruzant), Q5112
fam-trastuzumab deruxtecan-nxki, J9358
pkrb (Herzuma), Q5113
qyyp (trazimera), Q5116
Trastuzumab and Hyaluronidase-oysk, J9356
Treatment
bone, G0412–G0415
pediculosis (lice), A9180
services, behavioral health, H0002–H2037
Treprostinil, J3285
Triamcinolone, J3301–J3303
acetonide, J3300, J3301
diacetate, J3302
hexacetonide, J3303
inhalation solution, concentrated, J7683
inhalation solution, unit dose, J7684
Triferic avnu J1445
Triflupromazine HCl, J3400
Trifocal, glass or plastic, V2300–V2399
aniseikonic, V2318
lenticular, V2315, V2321
specialty trifocal, by report, V2399
sphere, plus or minus, V2300–V2302
spherocylinder, V2303–V2314
trifocal add-over 3.25d, V2320
trifocal, seg width over 28 mm, V2319
Trigeminal division block anesthesia, D9212
Trilaciclib J1448
Triluron intraarticular injection, J7332
Trimethobenzamide HCl, J3250
Trimetrexate glucuoronate, J3305
Trimming, nails, dystrophic, G0127
Triptorelin pamoate, J3315
Trismus appliance, D5937
Truss, L8300–L8330
addition to standard pad, scrotal pad, L8330
addition to standard pad, water pad, L8320
double, standard pads, L8310
single, standard pad, L8300
Tube/Tubing
anchoring device, A5200
blood, A4750, A4755
corrugated tubing, non-disposable, used with large volume nebulizer, 10 feet, A4337
drainage extension, A4331
gastrostomy, B4087, B4088
irrigation, A4355
larynectomy, A4622
nasogastric, B4081, B4082
oxygen, A4616
serum clotting time, A4771
stomach, B4083
suction pump, each, A7002
tire, K0091, K0093, K0095, K0097
tracheostomy, A4622
urinary drainage, K0280

U
Ultrasonic nebulizer, E0575
Ultrasound, S8055, S9024
paranasal sinus ultrasound, S9024
ultrasound guidance, multifetal pregnancy reduction, technical component, S8055
Ultraviolet, cabinet/system, E0691, E0694
Ultraviolet light therapy system, A4633, E0691–E0694
light therapy system in 6 foot cabinet, E0694
replacement bulb/lamp, A4633
therapy system panel, 4 foot, E0692
 therapy system panel, 6 foot, E0693
treatment area 2 sq feet or less, E0691
Unclassified drug, J3490
Underpads, disposable, A4554
Unipuncture control system, dialysis, E1580
Upper extremity addition, locking elbow, L6693
Upper extremity fracture orthosis, L3980–L3999
Upper limb prosthesis, L6000–L7499
Urea, J3350
Ureterostomy supplies, A4454–A4590
Urethral suppository, Alprostadil, J0275
Urinal, E0325, E0326
Urinary
catheter, A4338–A4346, A4351–A4353
indwelling catheter, A4338–A4346
intermittent urinary catheter, A4351–A4353
male external catheter, A4349
collection and retention (supplies), A4310–A4360
bedside drainage bag, A4357
disposable external urethral clamp, A4360
external urethral clamp, A4356
female external urinary collection device, A4328
insertion trays, A4310–A4316, A4354–A4355
irrigation syringe, A4322
irrigation tray, A4320
male external catheter/integral collection chamber, A4326
perianal fecal collection pouch, A4330
therapeutic agent urinary catheter irrigation, A4321
urinary drainage bag, leg/abdomen, A4358
supplies, external, A4335, A4356–A4358
bedside drainage bag, A4357
external urethral clamp/compression device, A4356
incontinence supply, A4335
urinary drainage bag, leg or abdomen, A4358
tract endoscope, C1747 ◀
tract implant, collagen, L8603
tract implant, synthetic, L8606
Urine
sensitivity study, P7001
system, K1006
tests, A4250
Urofollitropin, J3355
Urokinase, J3364, J3365
Ustekinumab, J3357, J3758
U-V lens, V2755

V
Vabra aspirator, A4480
Vaccination, administration
flublok, Q2033
hepatitis B, G0010
influenza virus, G0008
pneumococcal, G0009
Vaccine
administration, influenza, G0008
administration, pneumococcal, G0009
hepatitis B, administration, G0010
Vaginal
cancer, screening, G0101
cytopathologist, G0123
cytopathology, G0123, G0124, G0141–G0148
screening, cervical/vaginal, thin-layer, cytopathologist, G0123
screening, cervical/vaginal, thin-layer, physician interpretation, G0124
screening cytopathology smears, automated, G0141–G0148
Vancomycin HCl, J3370–J3372 ◀
Vaporizer, E0605
Vascular
catheter (appliances and supplies), A4300–A4306
disposable drug delivery system, >50 ml/hr, A4305
disposable drug delivery system, <50 ml/hr, A4306
implantable access catheter, external, A4300
implantable access total, catheter, A4301
graft material, synthetic, L8670
Vasoxyl, J3390
Vedolizumab, J3380
Vehicle, power-operated, K0800–K0899
Velaglucerase alfa, J3385
Venous pressure clamp, dialysis, A4918
Ventilator
battery, A4611–A4613
 home ventilator, any type, E0465, E0466
used with invasive interface (e.g., tracheostomy tube), E0465
used with non-invasive interface (e.g., mask, chest shell), E0466
moisture exchanger, disposable, A4483
Ventricular assist device, Q0478–Q0504, Q0506–Q0509
battery clips, electric or electric/pneumatic, replacement, Q0497
battery, lithium-ion, electric or electric/pneumatic, replacement, Q0506
battery, other than lithium-ion, electric or electric/pneumatic, replacement, Q0496
battery, pneumatic, replacement, Q0503
battery/power-pack charger, electric or electric/pneumatic, replacement, Q0495
belt/vest/bag, carry external components, replacement, Q0499
driver, replacement, Q0480
ejection, fraction, left, M1150 ◀
emergency hand pump, electric or electric/pneumatic, replacement, Q0494
emergency power source, electric, replacement, Q0490
emergency power source, electric/pneumatic, replacement, Q0491
emergency power supply cable, electric, replacement, Q0492
emergency power supply cable, electric/pneumatic, replacement, Q0493
filters, electric or electric/pneumatic, replacement, Q0500
holster, electric or electric/pneumatic, replacement, Q0498
leads (pneumatic/electrical), replacement, Q0487
microprocessor control unit, electric/pneumatic combination, replacement, Q0482
microprocessor control unit, pneumatic, replacement, Q0481
miscellaneous supply, external VAD, Q0507
miscellaneous supply, implanted device, Q0508
miscellaneous supply, implanted device, payment not made under Medicare Part A, Q0509
mobility cart, replacement, Q0502
monitor control cable, electric, replacement, Q0485
monitor control cable, electric/pneumatic, Q0486
monitor/display module, electric, replacement, Q0483
monitor/display module, electric/electric pneumatic, replacement, Q0484
power adapter, pneumatic, replacement, vehicle type, Q0504
power adapter, vehicle type, Q0478
power module, replacement, Q0479
power-pack base, electric, replacement, Q0488
power-pack base, electric/pneumatic, replacement, Q0489
shower cover, electric or electric/pneumatic, replacement, Q0501
Verteporfin, J3396
Vest, safety, wheelchair, E0980
Vinblastine sulfate, J9360
Vincristine sulfate, J9370, J9371
Vinorelbine tartrate, J9390
Vision service, V2020–V2799
bifocal, glass or plastic, V2200–V2299
contact lenses, V2500–V2599
frames, V2020–V2025
intraocular lenses, V2630–V2632
low-vision aids, V2600–V2615
miscellaneous, V2700–V2799
prosthetic eye, V2623–V2629
spectacle lenses, V2100–V2199
trifocal, glass or plastic, V2300–V2399
variable asphericity, V2410–V2499
Visit, emergency department, G0380–G0384
Visual, function, postoperative cataract surgery, G0915–G0918
Vitamin B-12 cyanocobalamin, J3420
Vitamin K, J3430
Voice
amplifier, L8510
prosthesis, L8511–L8514
Von Willebrand Factor Complex, human, J7179, J7183, J7187
Voriconazole, J3465
Vutrisiran, J0225 ◀

W
Waiver, T2012–T2050
assessment/plan of care development, T2024
case management, per month, T2022
day habilitation, per 15 minutes, T2021
day habilitation, per diem, T2020
habilitation, educational, per diem, T2012
habilitation, educational, per hour, T2013
habilitation, prevocational, per diem, T2014
habilitation, prevocational, per hour, T2015
habilitation, residential, 15 minutes, T2017
habilitation, residential, per diem, T2016
habilitation, supported employment, 15 minutes, T2019
habilitation, supported employment, per diem, T2018
targeted case management, per month, T2023
waiver services NOS, T2025
Walker, E0130–E0149
accessories, A4636, A4637
attachments, E0153–E0159
enclosed, four-sided frame, E0144
folding (pickup), E0135
folding, wheeled, E0143
heavy duty, multiple braking system, E0147
heavy duty, wheeled, rigid or folding, E0149
heavy duty, without wheels, E0148
rigid (pickup), E0130
rigid, wheeled, E0141
with trunk support, E0140
Walking splint, L4386
Washer, Gravlee jet, A4470
Water
dextrose, J7042, J7060, J7070
distilled (for nebulizer), A7018
pressure pad/mattress, E0187, E0198
purification system (ESRD), E1610, E1615
softening system (ESRD), E1625
sterile, A4714
WBC/CBC, G0306
Wedges, shoe, L3340–L3420
Wellness, promoting, M0005 ◀
Wellness visit; annual, G0438, G0439
Wet mount, Q0111
Wheel attachment, rigid pickup walker, E0155
Wheelchair, E0950–E1298, K0001–K0108, K0801–K0899
accessories, E0192, E0950–E1030, E1065–E1069, E2211–E2230, E2300–E2399,
E2626–E2633
amputee, E1170–E1200
back, fully reclining, manual, E1226
component or accessory, not otherwise specified, K0108
cushions, E2601–E2625
custom manual wheelchair base, K0008
custom motorized/power base, K0013
dynamic positioning hardware for back, E2398
foot box, E0954
heavy duty, E1280–E1298, K0006, K0007, K0801–K0886
lateral thigh or knee support, E0953
lightweight, E1087–E1090, E1240–E1270
 narrowing device, E0969
power add-on, E0983–E0984
reclining, fully, E1014, E1050–E1070, E1100–E1110
semi-reclining, E1100–E1110
shock absorber, E1015–E1018
specially sized, E1220, E1230
standard, E1130, K0001
stump support system, K0551
tire, E0999
transfer board or device, E0705
tray, K0107
van, non-emergency, A0130
youth, E1091
WHFO with inflatable air chamber, L3807
Whirlpool equipment, E1300–E1310
Whirlpool tub, walk-in, portable, K1003
WHO, wrist extension, L3914
Wig, A9282
Wipes, A4245, A4247
Wound
cleanser, A6260
closure, adhesive, G0168
cover
alginate dressing, A6196–A6198
collagen dressing, A6020–A6024
foam dressing, A6209–A6214
hydrocolloid dressing, A6234–A6239
hydrogel dressing, A6242–A6247
non-contact wound warming cover, and accessory, E0231–E0232
specialty absorptive dressing, A2001–A2010, A2015–2018, A6251–A6256 ◀
filler
alginate dressing, A6199
collagen based, A6010
foam dressing, A6215
hydrocolloid dressing, A6240–A6241
hydrogel dressing, A6248
not elsewhere classified, A6261–A6262
Woundfix, Woundfix Plus, Q4217
matrix, Q4114
pouch, A6154
therapy, negative, pressure, pump, E2402
 wound suction, A9272, K0743
Wrapping, fabric, abdominal aneurysm, M0301
Wrist
disarticulation prosthesis, L6050, L6055
electronic wrist rotator, L7259
hand/finger orthosis (WHFO), E1805, E1825, L3800–L3954

X
Xenon Xe 133, A9558
Xipere, J3299 ◀
X-ray
equipment, portable, Q0092, R0070, R0075
single, energy, absorptiometry (SEXA), G0130
transport, R0070–R0076
Xylocaine HCl, J2000

Y
Yttrium Y-90 ibritumomab, A9543

Z
Ziconotide, J2278
Zidovudine, J3485
Ziprasidone mesylate, J3486
Zoledronic acid, J3489
Zynlonta, J9359 ◀

◀ New Revised ✔ Reinstated deleted Deleted

TABLE OF DRUGS
IA Intra-arterial administration
IU International unit
IV Intravenous administration
IM Intramuscular administration
IT Intrathecal
SC Subcutaneous administration
INH Administration by inhaled solution
VAR Various routes of administration
OTH Other routes of administration
ORAL Administered orally

Intravenous administration includes all methods, such as gravity infusion, injections, and
timed pushes. The “VAR” posting denotes various routes of administration and is used for
drugs that are commonly administered into joints, cavities, tissues, or topical applications, in
addition to other parenteral administrations. Listings posted with “OTH” indicate other
administration methods, such as suppositories or catheter injections.

Blue typeface terms are added by publisher.

METHOD OF
DRUG NAME DOSAGE ADMINISTRATION HCPCS CODE

A
Abatacept 10 mg IV J0129
Abbokinase 5,000 IU IV J3364
vial
250,000 IV J3365
IU vial
Abbokinase, Open Cath 5,000 IU IV J3364
vial
Abciximab 10 mg IV J0130
Abelcet 10 mg IV J0287-J0289
Abilify Maintena 1 mg J0401
ABLC 50 mg IV J0285
AbobotulinumtoxinA 5 units IM J0586
Abraxane 1 mg J9264
Accuneb 1 mg J7613
Acetadote 100 mg J0132
Acetaminophen 10 mg IV J0131
Acetazolamide sodium up to 500 IM, IV J1120
mg
Acetylcysteine
injection 100 mg IV J0132
unit dose form per gram INH J7604,
J7608
Achromycin up to 250 IM, IV J0120
mg
Actemra 1 mg J3262
ACTH up to 40 IV, IM, SC J0800
units
Acthar up to 40 IV, IM, SC J0800
units
Acthib J3490
Acthrel 1 mcg J0795
Actimmune 3 million SC J9216
units
Activase 1 mg IV J2997
Acyclovir 5 mg J0133
J8499
Adagen 25 IU J2504
Adalimumab 20 mg SC J0135
Adcetris 1 mg IV J9042
Adenocard 1 mg IV J0153
Adenoscan 1 mg IV J0153
Adenosine 1 mg IV J0153
Ado-trastuzumab Emtansine 1 mg IV J9354
Adrenalin Chloride up to 1 ml SC, IM J0171
ampule
Adrenalin, epinephrine 0.1 mg SC, IM J0171
Adriamycin, PFS, RDF 10 mg IV J9000
Adrucil 500 mg IV J9190
Aduhelm 2 mg IV J0172
Advate per IU J7192
Afamelanotide implant 1 mg IV J7352
Aflibercept 1 mg OTH J0178
Agalsidase beta 1 mg IV J0180
Aggrastat 0.25 mg IM, IV J3246
A-hydrocort up to 50 IV, IM, SC J1710
mg
up to 100 J1720
mg
Akineton per 5 mg IM, IV J0190
Akynzeo 300 mg J8655
and 0.5
mg
Alatrofloxacin mesylate, injection 100 mg IV J0200
Albumin P9041,
P9045,
P9046,
P9047
Albuterol 0.5 mg INH J7620
concentrated form 1 mg INH J7610, J7611
 unit dose form 1 mg INH J7609,
J7613
Aldesleukin per single IM, IV J9015
use vial
Aldomet up to 250 IV J0210
mg
Aldurazyme 0.1 mg J1931
Alefacept 0.5 mg IM, IV J0215
Alemtuzumab 1 mg J0202
Alferon N 250,000 IM J9215
IU
Alglucerase per 10 IV J0205
units
Alglucosidase alfa 10 mg IV J0220,
J0221
Alimta 10 mg J9305
Alkaban-AQ 1 mg IV J9360
Alkeran 2 mg ORAL J8600
50 mg IV J9245
AlloDerm per square Q4116
centimeter
AlloSkin per square Q4115
centimeter
Aloxi 25 mcg J2469
Alpha 1-proteinase inhibitor, 10 mg IV J0256,
human J0257
Alphanate J7186
AlphaNine SD per IU J7193
Alprolix per IU J7201
Alprostadil
 injection 1.25 mcg OTH J0270

urethral suppository each OTH J0275

Alteplase recombinant 1 mg IV J2997
Alupent per 10 mg INH J7667,
J7668
noncompounded, unit dose 10 mg INH J7669
unit dose 10 mg INH J7670
AmBisome 10 mg IV J0289
Amcort per 5 mg IM J3302
A-methaPred up to 40 IM, IV J2920
mg
up to 125 IM, IV J2930
mg
Amgen 1 mcg SC J9212
Amifostine 500 mg IV J0207
Amikacin sulfate 100 mg IM, IV J0278
Aminocaproic Acid J3490
Aminolevulinic acid HCl unit dose OTH J7308
(354 mg)
Aminolevulinic acid HCl 10% Gel 10 mg OTH J7345
Aminolevulinate 1g OTH J7309
Aminophylline/Aminophyllin up to 250 IV J0280
mg
Amiodarone HCl 30 mg IV J0282
Amitriptyline HCl up to 20 IM J1320
mg
Amobarbital up to 125 IM, IV J0300
mg
Amphadase 1 ml J3470
Amphocin 50 mg IV J0285
Amphotericin B 50 mg IV J0285

Amphotericin B, lipid complex 10 mg IV J0287-J0289

Ampicillin
sodium up to 500 IM, IV J0290
mg
sodium/sulbactam sodium per 1.5 g IM, IV J0295
Amygdalin J3570
Amytal up to 125 IM, IV J0300
mg
Anabolin LA 100 up to 50 IM J2320
mg
Anadulafungin 1 mg IV J0348
Anascorp up to 120 IV J0716
mg
Anastrozole 1 mg J8999
Ancef 500 mg IV, IM J0690
Andrest 90-4 1 mg IM J3121
Andro-Cyp 1 mg J1071
Andro-Cyp 200 1 mg J1071
Andro L.A. 200 1 mg IM J3121
Andro-Estro 90-4 1 mg IM J3121
Andro/Fem 1 mg J1071
Androgyn L.A. 1 mg IM J3121
Androlone-50 up to 50 J2320
mg
Androlone-D 100 up to 50 IM J2320
mg
Andronaq-50 up to 50 IM J3140
mg

Andronaq-LA 1 mg J1071
Andronate-100 1 mg J1071
Andronate-200 1 mg J1071
Andropository 100 1 mg IM J3121
Andryl 200 1 mg IM J3121
Anectine up to 20 IM, IV J0330
mg
Anergan 25 up to 50 IM, IV J2550
mg
12.5 mg ORAL Q0169
Anergan 50 up to 50 IM, IV J2550
mg
12.5 mg ORAL Q0169
Angiomax 1 mg J0583
Anidulafungin 1 mg IV J0348
Anistreplase 30 units IV J0350
Antiflex up to 60 IM, IV J2360
mg
Anti-Inhibitor per IU IV J7198
Antispas up to 20 IM J0500
mg
Antithrombin III (human) per IU IV J7197
Antithrombin recombinant 50 IU IV J7196
Anzemet 10 mg IV J1260
50 mg ORAL S0174
100 mg ORAL Q0180
Apidra Solostar per 50 J1817
units
A.P.L. per 1,000 IM J0725
USP units
Apligraf per square Q4101
centimeter
Apomorphine Hydrochloride 1 mg SC J0364
Aprepitant 1 mg IV J0185
Aprepitant 5 mg ORAL J8501
Apresoline up to 20 IV, IM J0360
mg
Aprotinin 10,000 kiu J0365
AquaMEPHYTON per 1 mg IM, SC, IV J3430
Aralast 10 mg IV J0256
Aralen up to 250 IM J0390
mg
Aramine per 10 mg IV, IM, SC J0380
Aranesp
ESRD use 1 mcg J0882
Non-ESRD use 1 mcg J0881
Arbutamine 1 mg IV J0395
Arcalyst 1 mg J2793
Aredia per 30 mg IV J2430
Arfonad, see Trimethaphan
camsylate
Arformoterol tartrate 15 mcg INH J7605
Argatroban
(for ESRD use) 1 mg IV J0884, ◀
J0892,
J0899
(for non-ESRD use) 1 mg IV J0883, ◀
J0891,
J0898
Aridol 25% in 50 IV J2150
 ml
5 mg INH J7665
Arimidex J8999
Aripiprazole 0.25 mg IM J0400
Aripiprazole, extended release 1 mg IV J0401
Aripiprazole lauroxil 1 mg IV J1942
Aripiprazole lauroxil (aristada) 1 mg IV J1944
Aripiprazole lauroxil (aristada 1 mg IV J1943
initio)
Aristocort Forte per 5 mg IM J3302
Aristocort Intralesional per 5 mg IM J3302
Aristospan Intra-Articular per 5 mg VAR J3303
Aristospan Intralesional per 5 mg VAR J3303
Arixtra per 0.5 m J1652
Aromasin J8999
Arranon 50 mg J9261
Arrestin up to 200 IM J3250
mg
250 mg ORAL Q0173
Arsenic trioxide 1 mg IV J9017
Arzerra 10 mg J9302
Asparaginase 1,000 IV, IM J9019
units
10,000 IV, IM J9020
units
Astagraf XL 0.1 mg J7508
Astramorph PF up to 10 IM, IV, SC J2270
mg
Atezolizumab 10 mg IV J9022
Atgam 250 mg IV J7504

Ativan 2 mg IM, IV J2060

Atropine
concentrated form per mg INH J7635
unit dose form per mg INH J7636
sulfate 0.01 mg IV, IM, SC J0461,
J7636
Atrovent, unit dose form per mg INH J7644,
J7645
ATryn 50 IU IV J7196
Aurothioglucose up to 50 IM J2910
mg
Autologous cultured chondrocytes OTH J7330
implant
Autoplex T per IU IV J7198,
J7199
AUVI-Q 0.15 mg J0171
Avastin 10 mg J9035
Avelox 100 mg J2280
Avelumab 10 mg IV J9023
Avonex 30 mcg IM J1826
1 mcg IM Q3027
1 mcg SC Q3028
Azacitidine 1 mg SC J9025
Azasan 50 mg J7500
Azathioprine 50 mg ORAL J7500
Azathioprine, parenteral 100 mg IV J7501
Azithromycin, dihydrate 1 gram ORAL Q0144
Azithromycin, injection 500 mg IV J0456
B
Baciim J3490
Bacitracin J3490
Baclofen 10 mg IT J0475
Baclofen for intrathecal trial 50 mcg OTH J0476
Bactocill up to 250 IM, IV J2700
mg
BAL in oil per 100 IM J0470
mg
Bamlan and etesev IV M0245
Bamlanivimab and etesevima 2100 mg IV Q0245
Banflex up to 60 IV, IM J2360
mg
Basiliximab 20 mg J0480
BCG live intravesical instillation 1 mg OTH J9030
Bebulin per IU J7194
Beclomethasone inhalation per mg INH J7622
solution, unit dose form
Belantamab mafodotin-blmf 0.5 mg IV J9037
Belatacept 1 mg IV J0485
Beleodaq 10 mg J9032
Belimumab 10 mg IV J0490
Belinostat 10 mg IV J9032
Bena-D 10 up to 50 IV, IM J1200
mg
Bena-D 50 up to 50 IV, IM J1200
mg
Benadryl up to 50 IV, IM J1200
mg
Benahist 10 up to 50 IV, IM J1200
 mg
Benahist 50 up to 50 IV, IM J1200
mg
Ben-Allergin-50 up to 50 IV, IM J1200
mg
50 mg ORAL Q0163
Bendamustine HCl
Bendeka 1 mg IV J9034
Treanda 1 mg IV J9033
Bendamustine HCl 1 mg IV J9036
(Belrapzo/bendamustine)
Benefix per IU IV J7195
Benlysta 10 mg J0490
Benoject-10 up to 50 IV, IM J1200
mg
Benoject-50 up to 50 IV, IM J1200
mg
Benralizumab 1 mg IV J0517
Bentyl up to 20 IM J0500
mg
Benzocaine J3490
Benztropine mesylate per 1 mg IM, IV J0515
Berinert 10 units J0597
Berubigen up to IM, SC J3420
1,000 mcg
Beta amyloid per study OTH A9599
dose
Betalin 12 up to IM, SC J3420
1,000 mcg
Betameth per 3 mg IM, IV J0702
Betamethasone Acetate J3490
Betamethasone Acetate & per 3 mg IM J0702
Betamethasone Sodium Phosphate
Betamethasone inhalation solution, per mg INH J7624
unit dose form
Betaseron 0.25 mg SC J1830
Bethanechol chloride up to 5 mg SC J0520
Bethkis 300 mg J7682
Bevacizumab 10 mg IV J9035
Bevacizumab-awwb 10 mg IV Q5107
Bevacizumab-bvzr (Zirabev) 10 mg IV Q5118
Bezlotoxumab 10 mg IV J0565
Bicillin C-R 100,000 J0558
units
Bicillin C-R 900/300 100,000 IM J0558,
units J0561
Bicillin L-A 100,000 IM J0561
units
BiCNU 100 mg IV J9050
Biperiden lactate per 5 mg IM, IV J0190
Bitolterol mesylate
concentrated form per mg INH J7628
unit dose form per mg INH J7629
Bivalirudin 1 mg IV J0583
Blenoxane 15 units IM, IV, SC J9040
Bleomycin sulfate 15 units IM, IV, SC J9040
Blinatumomab 1 IV J9039
microgram
Blincyto 1 mcg J9039
Boniva 1 mg J1740
Bortezomib 0.1 mg IV J9041
Bortezomib, not otherwise 0.1 mg J9044 ◀
specified J9046,
J9048,
J9049
Botox 1 unit J0585
Bravelle 75 IU J3355
Brentuximab Vedotin 1 mg IV J9042
Brethine
concentrated form per 1 mg INH J7680
unit dose per 1 mg INH J7681
up to 1 mg SC, IV J3105
Bricanyl Subcutaneous up to 1 mg SC, IV J3105
Brompheniramine maleate per 10 mg IM, SC, IV J0945
Bronkephrine, see
Ethylnorepinephrine HCl
Bronkosol
concentrated form per mg INH J7647,
J7648
unit dose form per mg INH J7649,
J7650
Brovana J7605
Budesonide inhalation solution
concentrated form 0.25 mg INH J7633,
J7634
unit dose form 0.5 mg INH J7626,
J7627
Bumetanide J3490
Bupivacaine J3490
Buprenex 0.3 mg J0592
Buprenorphine Hydrochloride 0.1 mg IM J0592
Buprenorphine/Naloxone 1 mg ORAL J0571

< = 3 mg ORAL J0572

> 3 mg but ORAL J0573
< = 6 mg
> 6 mg but ORAL J0574
< = 10 mg
> 10 mg ORAL J0575
Buprenorphine extended release < = 100 ORAL Q9991
mg
> 100 mg ORAL Q9992
Burosumab-twza 1 mg IV J05894
Busulfan 1 mg IV J0594
2 mg ORAL J8510
Butorphanol tartrate 1 mg J0595
C
C1 Esterase Inhibitor 10 units IV J0596-J0599
Cabazitaxel 1 mg IV J9043
Cabergoline 0.25 mg ORAL J8515
Cabote Rilpivir 2 mg/3 mg IV J0741
Cabotegravir 1 mg IM J0739 ◀
Cafcit 5 mg IV J0706
Caffeine citrate 5 mg IV J0706
Caine-1 10 mg IV J2001
Caine-2 10 mg IV J2001
Calaspargase pegol-mknl 10 units IV J9118
Calcijex 0.1 mcg IM J0636
Calcimar up to 400 SC, IM J0630
units

Calcitonin-salmon up to 400 SC, IM J0630

 units
Calcitriol 0.1 mcg IM J0636
Calcitrol J8499
Calcium Disodium Versenate up to IV, SC, IM J0600
1,000 mg
Calcium gluconate per 10 ml IV J0610
Calcium glycerophosphate and per 10 ml IM, SC J0620
calcium lactate
Caldolor 100 mg IV J1741
Calphosan per 10 ml IM, SC J0620
Camcevi 1 mg IV J1952
Camptosar 20 mg IV J9206
Canakinumab 1 mg SC J0638
Cancidas 5 mg J0637
Capecitabine 150 mg ORAL J8520
500 mg ORAL J8521
Capsaicin patch per sq cm OTH J7336
Carbidopa 5 mg/levodopa 20 mg IV J7340
enteral suspension
Carbocaine per 10 ml VAR J0670
Carbocaine with Neo-Cobefrin per 10 ml VAR J0670
Carboplatin 50 mg IV J9045
Carfilzomib 1 mg IV J9047
Carimune 500 mg J1566
Carmustine 100 mg IV J9050
Carnitor per 1 g IV J1955
Carticel J7330

Casimersen 10 mg IV J1426
Caspofungin acetate 5 mg IV J0637
Cathflo Activase 1 mg J2997
Caverject per 1.25 J0270
mcg
Cayston 500 mg S0073
Cefadyl up to 1 g IV, IM J0710
Cefazolin sodium 500 mg IV, IM J0690
Cefepime hydrochloride 500 mg IV J0692
Cefiderocol 10 mg IV J0699
Cefizox per 500 IM, IV J0715
mg
Cefotaxime sodium per 1 g IV, IM J0698
Cefotetan J3490
Cefoxitin sodium 1g IV, IM J0694
Ceftaroline fosamil 1 mg IV J0712
Ceftazidime per 500 IM, IV J0713
mg
Ceftazidime and avibactam 0.5 IV J0714
g/0.125 g
Ceftizoxime sodium per 500 IV, IM J0715
mg
Ceftolozane 50 mg and IV J0695
Tazobactam 25 mg
Ceftriaxone sodium per 250 IV, IM J0696
mg
Cefuroxime sodium, sterile per 750 IM, IV J0697
mg
Celestone Soluspan per 3 mg IM J0702
CellCept 250 mg ORAL J7517
Cel-U-Jec per 4 mg IM, IV Q0511
Cenacort A-40 1 mg J3300
per 10 mg IM J3301
Cenacort Forte per 5 mg IM J3302
Centruroides Immune F(ab) up to 120 IV J0716
mg
Cephalothin sodium up to 1 g IM, IV J1890
Cephapirin sodium up to 1 g IV, IM J0710
Ceprotin 10 IU J2724
Ceredase per 10 IV J0205
units
Cerezyme 10 units J1786
Cerliponase alfa 1 mg IV J0567
Certolizumab pegol 1 mg SC J0717
Cerubidine 10 mg IV J9150
Cetirizine hydrochloride 0.5 mg IM J1201
Cetuximab 10 mg IV J9055
Chealamide per 150 IV J3520
mg
Chirhostim 1 mcg IV J2850
Chloramphenicol Sodium up to 1 g IV J0720
Succinate
Chlordiazepoxide HCl up to 100 IM, IV J1990
mg
Chloromycetin Sodium Succinate up to 1 g IV J0720
Chloroprocaine HCl per 30 ml VAR J2400 ◀
1mg J2401,
J2402
Chloroquine HCl up to 250 IM J0390
mg
Chlorothiazide sodium per 500 IV J1205
mg
Chlorpromazine 5 mg ORAL Q0161
Chlorpromazine HCl up to 50 IM, IV J3230
mg
Cholografin Meglumine per ml Q9961
Chorex-5 per 1,000 IM J0725
USP units
Chorex-10 per 1,000 IM J0725
USP units
Chorignon per 1,000 IM J0725
USP units
Chorionic Gonadotropin per 1,000 IM J0725
USP units
Choron 10 per 1,000 IM J0725
USP units
Cidofovir 375 mg IV J0740
Cilastatin sodium, imipenem per 250 IV, IM J0743
mg
Cimzia 1 mg SC J0717
Cinacalcet 1 mg ORAL J0604
Cinryze 10 units J0598
Cipro IV 200 mg IV J0706
Ciprofloxacin 200 mg IV J0706
otic suspension 6 mg OTH J7342
J3490
Cisplatin, powder or solution per 10 mg IV J9060
Cladribine per mg IV J9065
Claforan per 1 gm IM, IV J0698
Cleocin Phosphate J3490
Clindamycin J3490
Clofarabine 1 mg IV J9027
Clolar 1 mg J9027

Clonidine Hydrochloride 1 mg Epidural J0735

Coagulation factor Xa 10 mg J7169
(recombinant), inactivated-zhzo
(Andexxa)
Cobex up to IM, SC J3420
1,000 mcg
Codeine phosphate per 30 mg IM, IV, SC J0745
Codimal-A per 10 mg IM, SC, IV J0945
Cogentin per 1 mg IM, IV J0515
Colistimethate sodium up to 150 IM, IV J0770
mg
Collagenase, Clostridium 0.01 mg OTH J0775
Histolyticum
Coly-Mycin M up to 150 IM, IV J0770
mg
Compa-Z up to 10 IM, IV J0780
mg
Copanlisib 1 mg IV J9057
Compazine up to 10 IM, IV J0780
mg
5 mg ORAL Q0164
J8498
Compounded drug, not otherwise J7999
classified
Compro J8498
Conray per ml Q9961
Conray 30 per ml Q9958
Conray 43 per ml Q9960
Copaxone 20 mg J1595
Cophene-B per 10 mg IM, SC, IV J0945
Copper contraceptive, intrauterine OTH J7300
Cordarone 30 mg IV J0282
Corgonject-5 per 1,000 IM J0725
USP units
Corifact 1 IU J7180
Corticorelin ovine triflutate 1 mcg J0795
Corticotropin up to 40 IV, IM, SC J0800
units
Cortisone Acetate Micronized J3490
Cortrosyn per 0.25 IM, IV J0835
mg
Corvert 1 mg J1742
Cosmegen 0.5 mg IV J9120
Cosyntropin per 0.25 IM, IV J0833,
mg J0834
Cotranzine up to 10 IM, IV J0780
mg
Crizanlizumab-tmca IV J0791
Crofab up to 1 J0840
gram
Cromolyn Sodium J8499
Cromolyn sodium, unit dose form per 10 mg INH J7631,
J7632
Crotalidae immune f(ab’)2 (equine) 120 mg IV J0841
Crotalidae Polyvalent Immune Fab up to 1 IV J0840
gram
Crysticillin 600 A.S. up to IM, IV J2510
600,000
units
Cubicin 1 mg J0878

Cutaquig 100 mg IM J1551 ◀

Cuvitru J7799
Cyclophosphamide 100 mg IV J9070
oral 25 mg ORAL J8530
Cyclosporine 25 mg ORAL J7515
100 mg ORAL J7502
parenteral 250 mg IV J7516
Cymetra 1 cc Q4112
Cyramza 5 mg J9308
Cysto-Conray II per ml Q9958
Cystografin per ml Q9958
Cytarabine 100 mg SC, IV J9100
Cytarabine liposome 10 mg IT J9098
CytoGam per vial J0850
Cytomegalovirus immune globulin per vial IV J0850
intravenous (human)
Cytosar-U 100 mg SC, IV J9100
Cytovene 500 mg IV J1570
Cytoxan 100 mg IV J8530,
J9070
D
D-5-W, infusion 1000 cc IV J7070
Dacarbazine 100 mg IV J9130
Daclizumab 25 mg IV J7513
Dacogen 1 mg J0894
Dactinomycin 0.5 mg IV J9120
Dalalone 1 mg IM, IV, OTH J1100
Dalalone L.A. 1 mg IM J1094
Dalbavancin 5 mg IV J0875
Dalteparin sodium per 2500 SC J1645
IU
Daptomycin 1 mg IV J0877, ◀
J0878
Daratumumab 10 mg IV J9145
Darbepoetin Alfa 1 mcg IV, SC J0881,
J0882
Darzalex 10 mg J9145
Daunorubicin citrate, liposomal 10 mg IV J9151
formulation
Daunorubicin HCl 10 mg IV J9150
Daunoxome 10 mg IV J9151
DDAVP 1 mcg IV, SC J2597
Decadron 1 mg IM, IV, OTH J1100
0.25 mg J8540
Decadron Phosphate 1 mg IM, IV, OTH J1100
Decadron-LA 1 mg IM J1094
Deca-Durabolin up to 50 IM J2320
mg
Decaject 1 mg IM, IV, OTH J1100
Decaject-L.A. 1 mg IM J1094
Decitabine 1 mg IV J0893, ◀
J0894
Decolone-50 up to 50 IM J2320
mg
Decolone-100 up to 50 IM J2320
mg
De-Comberol 1 mg J1071
Deferoxamine mesylate 500 mg IM, SC, IV J0895
Definity per ml J3490,
Q9957
Degarelix 1 mg SC J9155
Dehist per 10 mg IM, SC, IV J0945
Deladumone 1 mg IM J3121
Deladumone OB 1 mg IM J3121
Delatest 1 mg IM J3121
Delatestadiol 1 mg IM J3121
Delatestryl 1 mg IM J3121
Delestrogen up to 10 IM J1380
mg
Delta-Cortef 5 mg ORAL J7510
Demadex 10 mg/ml IV J3265
Demerol HCl per 100 IM, IV, SC J2175
mg
Denileukin diftitox 300 mcg IV J9160
Denosumab 1 mg SC J0897
Deoxycholic acid 1 mg IM J0591
DepAndro 100 1 mg J1071
DepAndro 200 1 mg J1071
DepAndrogyn 1 mg J1071
DepGynogen up to 5 mg IM J1000
DepMedalone 40 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
DepMedalone 80 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
DepoCyt 10 mg J9098
Depo-estradiol cypionate up to 5 mg IM J1000
Depogen up to 5 mg IM J1000
Depoject 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
Depo-Medrol 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
Depopred-40 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
Depopred-80 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
Depo-Provera Contraceptive 1 mg J1050
Depotest 1 mg J1071
Depo-Testadiol 1 mg J1071
Depo-Testosterone 1 mg J1071
Depotestrogen 1 mg J1071
Dermagraft per square Q4106
centimeter
Desferal Mesylate 500 mg IM, SC, IV J0895
Desmopressin acetate 1 mcg IV, SC J2597
Dexacen-4 1 mg IM, IV, OTH J1100
Dexacen LA-8 1 mg IM J1094
Dexamethasone
 concentrated form per mg INH J7637
intravitreal implant 0.1 mg OTH J7312
lacrimal ophthalmic insert 0.1 mg OTH J1096
unit form per mg INH J7638
oral 0.25 mg ORAL J8540
acetate 1 mg IM J1094
sodium phosphate 1 mg IM, IV, OTH J1100
Dexasone 1 mg IM, IV, OTH J1100
Dexasone L.A. 1 mg IM J1094
Dexferrum 50 mg J1750
Dexone 0.25 mg ORAL J8540
1 mg IM, IV, OTH J1100
Dexone LA 1 mg IM J1094
Dexpak 0.25 mg ORAL J8540
Dexrazoxane hydrochloride 250 mg IV J1190
Dextran 40 500 ml IV J7100
Dextran 75 500 ml IV J7110
Dextrose 5%/normal saline 500 ml = 1 IV J7042
solution unit
Dextrose/water (5%) 500 ml = 1 IV J7060
unit
D.H.E. 45 per 1 mg J1110
Diamox up to 500 IM, IV J1120
mg
Diazepam up to 5 mg IM, IV J3360
Diazoxide up to 300 IV J1730
mg
Dibent up to 20 IM J0500
mg
Diclofenac sodium 37.5 IV J1130
Dicyclomine HCl up to 20 IM J0500
mg

Didronel per 300 IV J1436

mg
Diethylstilbestrol diphosphate 250 mg IV J9165
Diflucan 200 mg IV J1450
DigiFab per vial J1162
Digoxin up to 0.5 IM, IV J1160
mg
Digoxin immune fab (ovine) per vial J1162
Dihydrex up to 50 IV, IM J1200
mg
50 mg ORAL Q0163
Dihydroergotamine mesylate per 1 mg IM, IV J1110
Dilantin per 50 mg IM, IV J1165
Dilaudid up to 4 mg SC, IM, IV J1170
250 mg OTH S0092
Dilocaine 10 mg IV J2001
Dilomine up to 20 IM J0500
mg
Dilor up to 500 IM J1180
mg
Dimenhydrinate up to 50 IM, IV J1240
mg
Dimercaprol per 100 IM J0470
mg
Dimethyl sulfoxide 50%, 50 OTH J1212
ml
Dinate up to 50 IM, IV J1240
mg
Dioval up to 10 IM J1380
 mg

Dioval 40 up to 10 IM J1380
mg
Dioval XX up to 10 IM J1380
mg
Diphenacen-50 up to 50 IV, IM J1200
mg
50 mg ORAL Q0163
Diphenhydramine HCl
IV up to 50 IV, IM J1200
mg
oral 50 mg ORAL Q0163
Diprivan 10 mg J2704
J3490
Dipyridamole per 10 mg IV J1245
Disotate per 150 IV J3520
mg
Di-Spaz up to 20 IM J0500
mg
Ditate-DS 1 mg IM J3121
Diuril Sodium per 500 IV J1205
mg
D-Med 80 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
DMSO, Dimethyl sulfoxide 50% 50 ml OTH J1212
Dobutamine HCl per 250 IV J1250
mg
Dobutrex per 250 IV J1250
mg
Docefrez 1 mg J9171

Docetaxel 20 mg IV J9170
Dolasetron mesylate
injection 10 mg IV J1260
tablets 100 mg ORAL Q0180
Dolophine HCl up to 10 IM, SC J1230
mg
Dommanate up to 50 IM, IV J1240
mg
Donbax 10 mg J1267
Dopamine 40 mg J1265
Dopamine HCl 40 mg J1265
Doribax 10 mg J1267
Doripenem 10 mg IV J1267
Dornase alpha, unit dose form per mg INH J7639
Dotarem 0.1 ml A9575
Doxercalciferol 1 mcg IV J1270
Doxil 10 mg IV J9000,
Q2050
Doxorubicin HCL 10 mg IV J9000
Doxy 100 mg J3490
Dramamine up to 50 IM, IV J1240
mg
Dramanate up to 50 IM, IV J1240
mg
Dramilin up to 50 IM, IV J1240
mg
Dramocen up to 50 IM, IV J1240
mg
Dramoject up to 50 IM, IV J1240
mg

Dronabinol 2.5 mg ORAL Q0167

Droperidol up to 5 mg IM, IV J1790
Droperidol and fentanyl citrate up to 2 ml IM, IV J1810
ampule
Droxia ORAL J8999
Drug administered through a INH J3535
metered dose inhaler
DTIC-Dome 100 mg IV J9130
Dua-Gen L.A. 1 mg IM J3121
DuoNeb up to 2.5 J7620
mg
Duopa 20 ml J7340
Duoval P.A. 1 mg IM J3121
Durabolin up to 50 IM J2320
mg
Duracillin A.S. up to IM, IV J2510
600,000
units
Duraclon 1 mg Epidural J0735
Dura-Estrin up to 5 mg IM J1000
Duragen-10 up to 10 IM J1380
mg
Duragen-20 up to 10 IM J1380
mg
Duragen-40 up to 10 IM J1380
mg
Duralone-40 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
Duralone-80 20 mg IM J1020
40 mg IM J1030

80 mg IM J1040
Duralutin, see
Hydroxyprogesterone Caproate
Duramorph up to 10 IM, IV, SC J2270,
mg J2274
Duratest-100 1 mg J1071
Duratest-200 1 mg J1071
Duratestrin 1 mg J1071
Durathate-200 1 mg IM J3121
Durvalumab 10 mg IV J9173
Dymenate up to 50 IM, IV J1240
mg
Dyphylline up to 500 IM J1180
mg
Dysport 5 units J0586
Dalvance 5 mg J0875
E
Ecallantide 1 mg SC J1290
Eculizumab 10 mg IV J1300
Edaravone 1 mg IV J1301
Edetate calcium disodium up to IV, SC, IM J0600
1,000 mg
Edetate disodium per 150 IV J3520
mg
Efgartigimod 2 mg IM J9332 ◀
Elaprase 1 mg J1743
Elavil up to 20 IM J1320
 mg
Elelyso 10 units J3060

Eligard 7.5 mg J9217

Elitek 0.5 mg J2783
Ellence 2 mg J9178
Elliotts B solution 1 ml OTH J9175
Eloctate per IU J7205
Elosulfase alfa 1 mg IV J1322
Elotuzumab 1 mg IV J9176
Eloxatin 0.5 mg J9263
Elspar 10,000 IV, IM J9020
units
Emapalunab-lzsg 1 mg IV J9210
Emend J1453,
J8501
Emete-Con, see Benzquinamide
Eminase 30 units IV J0350
Empliciti 1 mg J9176
Enbrel 25 mg IM, IV J1438
Endrate ethylenediamine-tetra- per 150 IV J3520
acetic acid mg
Enfortumab vedotin-ejfv 0.25 mg IM J9177
Enfuvirtide 1 mg SC J1324
Engerix-B J3490
Enovil up to 20 IM J1320
mg
Enoxaparin sodium 10 mg SC J1650
Entyvio J3380
Eovist 1 ml A9581

Epinephrine J7799
Epinephrine, adrenalin 0.1 mg SC, IM J0171
Epirubicin hydrochloride 2 mg J9178
Epoetin alfa, ESRD use 100 units IV, SC Q4081
Epoetin alfa, non-ESRD use 1000 units IV J0885
Epoetin alfa-epbx (Retacrit) ESRD 100 units IV Q5105
use
Epoetin alfa-epbx (Retacrit) non- 1000 units IV Q5106
ESRD use
Epoetin beta, ESRD use 1 mcg IV J0887
Epoetin beta, non-ESRD use 1 mcg IV J0888
Epogen 1,000 J0885
units
Q4081
Epoprostenol 0.5 mg IV J1325
Eptifibatide, injection 5 mg IM, IV J1327
Eravacycline 1 mg IV J0122
Eraxis 1 mg IV J0348
Erbitux 10 mg J9055
Ergonovine maleate up to 0.2 IM, IV J1330
mg
Eribulin mesylate 0.1 mg IV J9179
Erivedge 150 mg J8999
Ertapenem sodium 500 mg IM, IV J1335
Erwinase 1,000 IV, IM J9019
units
10,000 IV, IM J9020
units
Erythromycin lactobionate 500 mg IV J1364
Estra-D up to 5 mg IM J1000
Estradiol
L.A. up to 10 IM J1380
mg
L.A. 20 up to 10 IM J1380
mg
L.A. 40 up to 10 IM J1380
mg
Estradiol cypionate up to 5 mg IM J1000
Estradiol valerate up to 10 IM J1380
mg
Estra-L 20 up to 10 IM J1380
mg
Estra-L 40 up to 10 IM J1380
mg
Estra-Testrin 1 mg IM J3121
Estro-Cyp up to 5 mg IM J1000
Estrogen, conjugated per 25 mg IV, IM J1410
Estroject L.A. up to 5 mg IM J1000
Estrone per 1 mg IM J1435
Estrone 5 per 1 mg IM J1435
Estrone Aqueous per 1 mg IM J1435
Estronol per 1 mg IM J1435
Estronol-L.A. up to 5 mg IM J1000
Etanercept, injection 25 mg IM, IV J1438
Etelcalcetide 0.1 mg IV Q4078
Eteplirsen 10 mg IV J1428
Ethamolin 100 mg J1430
Ethanolamine 100 mg J1430,
J3490
Ethyol 500 mg IV J0207

Etidronate disodium per 300 IV J1436

mg
Etonogestrel implant J7307
Etopophos 10 mg IV J9181
Etoposide 10 mg IV J9181
oral 50 mg ORAL J8560
Euflexxa per dose OTH J7323
Everolimus 0.25 mg ORAL J7527
Everone 1 mg IM J3121
Evinacumab-dgnb 5 mg IV J1305
Evomela 50 mg J9245
Eylea 1 mg OTH J0178
F
Fabrazyme 1 mg IV J0180
Factor IX
anti-hemophilic factor, per IU IV J7193
purified, non-recombinant
anti-hemophilic factor, per IU IV J7195,
recombinant J7200-
J7202
complex per IU IV J7194
Factor VIIa (coagulation factor, 1 mcg IV J7189
recombinant)
Factor VIII (anti-hemophilic per IU IV J7208
factor)
human per IU IV J7190
porcine per IU IV J7191
recombinant per IU IV J7182,
J7185,
J7192,
J7188
Factor VIII (anti-hemophilic
factor, recombinant)
(Afstyla) per IU IV J7210
Esperoct per IU IV J7204
Jivi per IU IV J7208
(Kovaltry) per IU IV J7211
Novoeight per IU IV J7182
Obizur per IU IV J7188
Xyntha per IU IV J7185
Factor VIII, anti-hemophilic per IU IV J7204
factor (recombinant)(esperoct)
Factor VIII Fc fusion per IU IV J7205,
(recombinant) J7207,
 J7209
Factor X (human) per IU IV J7175
Factor XIII A-subunit per IU IV J7181
(recombinant)
Factors, other hemophilia clotting per IU IV J7196
Factrel per 100 mcg SC, IV J1620
Fam-trastuzumab deruxtecan- 1 mg IM J9358
nxki
Famotidine J3490
Faricimab-svoa 0.1 mg IM J2777 ◀
Faslodex 25 mg J9395
Feiba NF J7198
Feiba VH Immuno per IU IV J7196
Fentanyl citrate 0.1 mg IM, IV J3010
Feraheme 1 mg Q0138,
Q0139
Ferric carboxymaltose 1 mg IV J1439
Ferric pyrophosphate citrate 0.1 mg of iron IV J1444
powder
Ferric pyrophosphate citrate 0.1 mg of iron IV J1443
solution (triferic)
Ferric pyrophosphate citrate 0.1 mg of iron IV J1445
solution (triferic avnu)
Ferrlecit 12.5 mg J2916
Ferumoxytol 1 mg Q0138,
Q0139
Filgrastim-aafi 1 mcg IV Q5110
Filgrastim
(G-CSF) 1 mcg SC, IV J1442,
Q5101
(TBO) 1 mcg IV J1447
Firazyr 1 mg SC J1744
Firmagon 1 mg J9155
Flebogamma 500 mg IV J1572
1 cc J1460
Flexoject up to 60 mg IV, IM J2360
Flexon up to 60 mg IV, IM J2360
Flolan 0.5 mg IV J1325
Flo-Pred 5 mg J7510
Florbetaben f18, diagnostic per study dose IV Q9983
Floxuridine 500 mg IV J9200
Fluconazole 200 mg IV J1450
Fludara 1 mg ORAL J8562
50 mg IV J9185
Fludarabine phosphate 1 mg ORAL J8562
50 mg IV J9185
Flunisolide inhalation solution, per mg INH J7641
unit dose form
Fluocinolone OTH J7311,
J7313
Fluocinolone acetonide (Yutiq) 0.01 mg OTH J7314
Fluorouracil 500 mg IV J9190
Fluphenazine decanoate up to 25 mg J2680
Flutamide J8999
Flutemetamol f18, diagnostic per study dose IV Q9982
Folex 5 mg IA, IM, IT, J9250
IV
50 mg IA, IM, IT, J9260
IV

Folex PFS 5 mg IA, IM, IT, J9250

IV
 50 mg IA, IM, IT, J9260
IV
Follutein per 1,000 USP IM J0725
units
Folotyn 1 mg J9307
Fomepizole 15 mg J1451
Fomivirsen sodium 1.65 mg Intraocular J1452
Fondaparinux sodium 0.5 mg SC J1652
Formoterol 12 mcg INH J7640
Formoterol fumarate 20 mcg INH J7606
Fortaz per 500 mg IM, IV J0713
Fosaprepitant 1 mg IV J1453, ◀
J1456
Foscarnet sodium per 1,000 mg IV J1455
Foscavir per 1,000 mg IV J1455
Fosnetupitant 235 mg and IV J1454
palonosetron 0.25 mg
Fosphenytoin 50 mg IV Q2009
Fragmin per 2,500 IU J1645
Fremanezumab-vfrm 1 mg IV J3031
FUDR 500 mg IV J9200
Fulvestrant 25 mg IM J9393, ◀
J9394,
J9395
Fungizone intravenous 50 mg IV J0285
Furomide M.D. up to 20 mg IM, IV J1940
Furosemide up to 20 mg IM, IV J1940
G
Gablofen 10 mg J0475
50 mcg J0476
Gadavist 0.1 ml A9585
Gadoxetate disodium 1 ml IV A9581
Gallium nitrate 1 mg IV J1457
Galsulfase 1 mg IV J1458
Gamastan 1 cc IM J1460
over 10 cc IM J1560
Gamma globulin 1 cc IM J1460
over 10 cc IM J1560
Gammagard Liquid 500 mg IV J1569
Gammagard S/D J1566
GammaGraft per square Q4111
centimeter
Gammaplex 500 mg IV J1557
Gammar 1 cc IM J1460
over 10 cc IM J1560
Gammar-IV, see Immune globin
intravenous (human)
Gamulin RH
immune globulin, human 100 IU J2791
1 dose package, IM J2790
300 mcg
immune globulin, human, 100 IU IV J2792
solvent detergent
Gamunex 500 mg IV J1561
Ganciclovir, implant 4.5 mg OTH J7310
Ganciclovir sodium 500 mg IV J1570, ◀
J1574
Ganirelix J3490

Garamycin, gentamicin up to 80 mg IM, IV J1580

Gastrografin per ml Q9963
Gatifloxacin 10 mg IV J1590
Gazyva 10 mg J9301
Gefitinib 250 mg ORAL J8565
Gel-One per dose OTH J7326
Gemcitabine HCl 200 mg IV J9201
Gemcitabine HCl, not otherwise 200 mg IV J9201
specified
Gemcitabine HCI (Infugem) 100 mg IV J9198
Gemsar 200 mg IV J9201
Gemtuzumab ozogamicin 5 mg IV J9300
Gengraf 100 mg J7502
25 mg ORAL J7515
Genotropin 1 mg J2941
Gentamicin Sulfate up to 80 mg IM, IV J1580,
J7699
Gentran 500 ml IV J7100
Gentran 75 500 ml IV J7110
Geodon 10 mg J3486
Gesterol 50 per 50 mg J2675
Givosiran 0.5 mg IM J0223
Glassia 10 mg IV J0257
Glatiramer Acetate 20 mg SC J1595
Gleevec (Film-Coated) 400 mg J8999
GlucaGen per 1 mg J1610
Glucagon HCl per 1 mg SC, IM, IV J1610, ◀
J1611
Glukor per 1,000 USP IM J0725
units
Glycopyrrolate
concentrated form per 1 mg INH J7642
unit dose form per 1 mg INH J7643
Gold sodium thiomalate up to 50 mg IM J1600
Golimumab 1 mg IV J1602
Golodirsen 10 mg IM J1429
Gonadorelin HCl per 100 mcg SC, IV J1620
Gonal-F J3490
Gonic per 1,000 USP IM J0725
units
Goserelin acetate implant per 3.6 mg SC J9202
Graftjacket per square Q4107
centimeter
Graftjacket Xpress 1 cc Q4113
Granisetron HCl
extended release 0.1 mg IV J1627
injection 100 mcg IV J1626
oral 1 mg ORAL Q0166
Guselkumab 1 mg IV J1628
Gynogen L.A. A10 up to 10 mg IM J1380
Gynogen L.A. A20 up to 10 mg IM J1380
Gynogen L.A. A40 up to 10 mg IM J1380
H
Halaven 0.1 mg J9179
Haldol up to 5 mg IM, IV J1630
Haloperidol up to 5 mg IM, IV J1630
Haloperidol decanoate per 50 mg IM J1631
Haloperidol Lactate up to 5 mg J1630
Hectoral 1 mcg IV J1270
Helixate FS per IU J7192
Hemin 1 mg J1640
Hemofil M per IU IV J7190
Hemophilia clotting factors (e.g., per IU IV J7198
anti-inhibitors)
NOC per IU IV J7199
Hepagam B 0.5 ml IM J1571
0.5 ml IV J1573
Heparin sodium 1,000 units IV, SC J1643, ◀
J1644
Heparin sodium (heparin lock 10 units IV J1642
flush)
Heparin Sodium (Procine) per 1,000 units J1644
Hep-Lock 10 units IV J1642
Hep-Lock U/P 10 units IV J1642
Herceptin 10 mg IV J9355
Hexabrix 320 per ml Q9967
Hexadrol Phosphate 1 mg IM, IV, J1100
OTH
Hexaminolevulinate 100 mg IV A9589
hydrochloride
Histaject per 10 mg IM, SC, IV J0945
Histerone 50 up to 50 mg IM J3140
Histerone 100 up to 50 mg IM J3140
Histrelin
acetate 10 mcg J1675
implant 50 mg OTH J9225,
J9226
Hizentra, see Immune globulin
Humalog per 5 units J1815
 per 50 units J1817
Human fibrinogen concentrate 100 mg IV J7178
Human fibrinogen concentrate 1 mg IV J7177
(fibryga)
Humate-P per IU J7187
Humatrope 1 mg J2941
Humira 20 mg J0135
Humulin per 5 units J1815
per 50 units J1817
Hyalgan, Spurtaz or VISCO-3 per dose IA J7321
Hyaluronan or derivative per dose IV J7327
Durolane 1 mg IA J7318
Gel-Syn 0.1 mg IA J7328
Gelsyn-3 0.1 mg IV J7328
Gen Visc 850 1 mg IA J7320
Hyalgan or supartz per dose IA J7321
Hymovis 1 mg IA J7322
Synojoynt 1 mg VAR J7331
Triluron 1 mg IV J7332
Trivisc 1 mg IV J7329
Hyaluronic Acid J3490
Hyaluronidase up to 150 units SC, IV J3470
Hyaluronidase
ovine up to 999 units VAR J3471
ovine per 1000 units VAR J3472
recombinant 1 usp SC J3473
Hyate:C per IU IV J7191
Hybolin Decanoate up to 50 mg IM J2320
Hycamtin 0.25 mg ORAL J8705
4 mg IV J9351
Hydralazine HCl up to 20 mg IV, IM J0360
Hydrate up to 50 mg IM, IV J1240
Hydrea J8999
Hydrocortisone acetate up to 25 mg IV, IM, SC J1700
Hydrocortisone sodium up to 50 mg IV, IM, SC J1710
phosphate
Hydrocortisone succinate sodium up to 100 mg IV, IM, SC J1720
Hydrocortone Acetate up to 25 mg IV, IM, SC J1700
Hydrocortone Phosphate up to 50 mg IM, IV, SC J1710
Hydromorphone HCl up to 4 mg SC, IM, IV J1170
Hydroxyprogesterone Caproate 1 mg IM J1725
(Makena) 10 mg IV J1726
NOS 10 mg IV J1729
Hydroxyurea J8999
Hydroxyzine HCl up to 25 mg IM J3410
Hydroxyzine Pamoate 25 mg ORAL Q0177
Hylan G-F 20 OTH J7322
Hylenex 1 USP unit J3473
Hyoscyamine sulfate up to 0.25 mg SC, IM, IV J1980
Hyperrho S/D 300 mcg J2790
100 IU J2792
Hyperstat IV up to 300 mg IV J1730
Hyper-Tet up to 250 units IM J1670
HypRho-D 300 mcg IM J2790
J2791

50 mcg J2788
Hyrexin-50 up to 50 mg IV, IM J1200
Hyzine-50 up to 25 mg IM J3410
I
Ibalizumab-uiyk 10 mg IV J1746
Ibandronate sodium 1 mg IV J1740
Ibuprofen 100 mg IV J1741
Ibutilide fumarate 1 mg IV J1742
Icatibant 1 mg SC J1744
Idamycin 5 mg IV J9211
Idarubicin HCl 5 mg IV J9211
Idursulfase 1 mg IV J1743
Ifex 1g IV J9208
Ifosfamide 1g IV J9208
Ilaris 1 mg J0638
Iloprost 20 mcg INH Q4074
Ilotycin, see Erythromycin
lactobionate
Iluvien 0.01 mg J7313
Imferon 50 mg J1750
Imiglucerase 10 units IV J1786
Imipenem 4 mg, cilistatin 4 mg, J0742
relebactam 2 mg
Imitrex 6 mg SC J3030
Imlygic per 1 million J9325,
plaque forming J9999
units
Immune globulin
Asceniv 500 mg IV J1554
Bivigam 500 mg IV J1556
 Cuvitru 100 mg IV J1555
Flebogamma 500 mg IV J1572
Gammagard Liquid 500 mg IV J1569
Gammaplex 500 mg IV J1557
Gamunex 500 mg IV J1561
HepaGam B 0.5 ml IM J1571
0.5 ml IV J1573
Hizentra 100 mg SC J1559
Hyaluronidase, (HYQVIA) 100 mg IV J1575
NOS 500 mg IV J1566,
J1599
Octagam 500 mg IV J1568
Privigen 500 mg IV J1459
Rhophylac 100 IU IM J2791
Subcutaneous 100 mg SC J1562
Xembify 100 mg IM J1558
Immunosuppressive drug, not J7599
otherwise classified
Imuran 50 mg ORAL J7500
100 mg IV J7501
Inapsine up to 5 mg IM, IV J1790
Inclisiran 1 mg IM J1306 ◀
Incobotulinumtoxin type A 1 unit IM J0588
Increlex 1 mg J2170
Inderal up to 1 mg IV J1800
Inebilizumab-cdon 1 mg IV J1823
Infed 50 mg J1750
Infergen 1 mcg SC J9212
Inflectra Q5102
Infliximab
dyyb 10 mg IM, IV Q5103
abda 10 mg IM, IV Q5104
axxq, biosimilar, (AVSOLA) 10 mg IM, IV Q5121
qbtx 10 mg IM, IV Q5109
Infumorph 10 mg J2274
Injectafer 1 mg J1439
Injection factor XL, 1 IU IV J7203
glycopegylated
Injection sulfur hexafluoride lipid per ml IV Q9950
microspheres
Innohep 1,000 iu SC J1655
Innovar up to 2 ml ampule IM, IV J1810
Inotuzumab orogamicin 0.1 mg IV J9229
Insulin 5 units SC J1815
Insulin-Humalog per 50 units J1817
Insulin lispro 50 units SC J1817
Intal, unit dose form per 10 mg INH J7631,
J7632
Integra
Bilayer Matrix Wound per square Q4104
Dressing (BMWD) centimeter
Dermal Regeneration Template per square Q4105
(DRT) centimeter
Flowable Wound Matrix 1 cc Q4114
Matrix per square Q4108
centimeter
Integrilin IV injection 5 mg IM, IV J1327
Interferon alfa-2a, recombinant 3 million units SC, IM J9213
Interferon alfa-2b, recombinant 1 million units SC, IM J9214
Interferon alfa-n3 (human 250,000 IU IM J9215
leukocyte derived)
Interferon alphacon-1, 1 mcg SC J9212
recombinant
Interferon beta-1a 30 mcg IM J1826
1 mcg IM Q3027
1 mcg SC Q3028
Interferon beta-1b 0.25 mg SC J1830
Interferon gamma-1b 3 million units SC J9216
Intrauterine copper contraceptive OTH J7300
Intron-A 1 million units J9214
Invanz 500 mg J1335
Invega Sustenna 1 mg J2426
Ipilimumab 1 mg IV J9228
Ipratropium bromide, unit dose per mg INH J3535,
form J7620,
J7644,
J7645
Irinotecan 20 mg IV J9206,
J9205
Iron dextran 50 mg IV, IM J1750
Iron sucrose 1 mg IV J1756
Irrigation solution for Tx of per 50 ml OTH Q2004
bladder calculi
Isatuximab-irfc 10 mg IV J9227
Isavuconazonium 1 mg IV J1833
Isocaine HCl per 10 ml VAR J0670

Isoetharine HCl
concentrated form per mg INH J7647,
J7648
 unit dose form per mg INH J7649,
J7650
Isoproterenol HCl
concentrated form per mg INH J7657,
J7658
unit dose form per mg INH J7659,
J7660
Isovue per ml Q9966,
Q9967
Isuprel
concentrated form per mg INH J7657,
J7658
unit dose form per mg INH J7659,
J7660
Itraconazole 50 mg IV J1835
Ixabepilone 1 mg IV J9207
Ixempra 1 mg J9207
J
Jemperli 10 mg IV J9272
Jenamicin up to 80 mg IM, IV J1580
Jetrea 0.125 mg J7316
Jevtana 1 mg J9043
K
Kabikinase per 250,000 IU IV J2995
Kadcyla 1 mg J9354
Kalbitor 1 mg J1290
Kaleinate per 10 ml IV J0610
Kanamycin sulfate up to 75 mg IM, IV J1850

up to 500 mg IM, IV J1840

Kantrex up to 75 mg IM, IV J1850
 up to 500 mg IM, IV J1840
Keflin up to 1 g IM, IV J1890
Kefurox per 750 mg J0697
Kefzol 500 mg IV, IM J0690
Kenaject-40 1 mg J3300
per 10 mg IM J3301
Kenalog-10 1 mg J3300
per 10 mg IM J3301
Kenalog-40 1 mg J3300
per 10 mg IM J3301
Kepivance 50 mcg J2425
Keppra 10 mg J1953
Keroxx 1 cc IV Q4202
Kestrone 5 per 1 mg IM J1435
Ketorolac tromethamine per 15 mg IM, IV J1885
Key-Pred 25 up to 1 ml IM J2650
Key-Pred 50 up to 1 ml IM J2650
Key-Pred-SP, see Prednisolone
sodium phosphate
Keytruda 1 mg J9271
K-Flex up to 60 mg IV, IM J2360
Khapzory 0.5 mg IV J0642
Kinevac 5 mcg IV J2805
Kitabis PAK per 300 mg J7682
Klebcil up to 75 mg IM, IV J1850
up to 500 mg IM, IV J1840

Koate-HP (anti-hemophilic
factor)
 human per IU IV J7190
porcine per IU IV J7191
recombinant per IU IV J7192
Kogenate
human per IU IV J7190
porcine per IU IV J7191
recombinant per IU IV J7192
Konakion per 1 mg IM, SC, IV J3430
Konyne-80 per IU IV J7194
Krystexxa 1 mg J2507
Kyleena 19.5 mg OTH J7296
Kyprolis 1 mg J9047
Kytril 1 mg ORAL Q0166
1 mg IV S0091
100 mcg IV J1626
L
L.A.E. 20 up to 10 mg IM J1380
Laetrile, Amygdalin, vitamin B- J3570
17
Lanadelumab-flyo 1 mg IV J0593
Lanoxin up to 0.5 mg IM, IV J1160
Lanreotide 1 mg SC J1930, ◀
J1932
Lantus per 5 units J1815
Largon, see Propiomazine HCl
Laronidase 0.1 mg IV J1931
Lasix up to 20 mg IM, IV J1940

L-Caine 10 mg IV J2001
Lefamulin 1 mg J0691
Lemtrada 1 mg J0202
Lepirudin 50 mg J1945
Leucovorin calcium per 50 mg IM, IV J0640
Leukeran J8999
Leukine 50 mcg IV J2820
Leuprolide acetate per 1 mg IM J9218
Leuprolide acetate (for depot per 3.75 mg IM J1950
suspension)
7.5 mg IM J9217
Leuprolide acetate (for depot 0.25 mg IV J1951
suspension) (fensolvi)
Leuprolide acetate implant 65 mg OTH J9219
Leustatin per mg IV J9065
Levalbuterol HCl
concentrated form 0.5 mg INH J7607,
J7612
unit dose form 0.5 mg INH J7614,
J7615
Levaquin I.U. 250 mg IV J1956
Levetiracetam 10 mg IV J1953
Levocarnitine per 1 gm IV J1955
Levo-Dromoran up to 2 mg SC, IV J1960
Levofloxacin 250 mg IV J1956
Levoleucovorin NOS 0.5 mg IV J0641
Levonorgestrel implant OTH J7306
Levonorgestrel-releasing 52 mg OTH J7297,
intrauterine contraceptive system J7298
Kyleena 19.5 mg OTH J7296
Levorphanol tartrate up to 2 mg SC, IV J1960
Levsin up to 0.25 mg SC, IM, IV J1980
Levulan Kerastick unit dose (354 OTH J7308
mg)
Lexiscan 0.1 mg J2785
Librium up to 100 mg IM, IV J1990
Lidocaine HCl 10 mg IV J2001
Lidoject-1 10 mg IV J2001
Lidoject-2 10 mg IV J2001
Liletta 52 mg OTH J7297
Lincocin up to 300 mg IV J2010
Lincomycin HCl up to 300 mg IV J2010
Linezolid 200 mg IV J2020, ◀
J2021
Lioresal 10 mg IT J0475
J0476
Liposomal
Cytarabine 2.27 mg IV J9153
Daunorubicin 1 mg IV J9153
Liquaemin Sodium 1,000 units IV, SC J1644
LMD (10%) 500 ml IV J7100
Locort 1.5 mg J8540
Lorazepam 2 mg IM, IV J2060
Lovenox 10 mg SC J1650
Loxapine 1 mg OTH J2062
Lucentis 0.1 mg J2778
Lufyllin up to 500 mg IM J1180
Lumasiran 0.5 mg IV J0224
Lumason per ml Q9950
Luminal Sodium up to 120 mg IM, IV J2560
Lumizyme 10 mg J0221
Lupon Depot 7.5 mg J9217
3.75 mg J1950
Lupron per 1 mg IM J9218
per 3.75 mg IM J1950
7.5 mg IM J9217
Lurbinectedin 0.1 mg IV J9223
Luspatercept-aamt 0.25 mg IM J0896
Lyophilized, see
Cyclophosphamide, lyophilized
M
Macugen 0.3 mg J2503
Magnesium sulfate 500 mg J3475
Magnevist per ml A9579
Makena 1 mg J1725
Mannitol 25% in 50 ml IV J2150
5 mg INH J7665
Marcaine J3490
Margetuximab-cmkb 5 mg IV J9353
Marinol 2.5 mg ORAL Q0167
Marmine up to 50 mg IM, IV J1240
Matulane 50 mg J8999
Maxipime 500 mg IV J0692
MD-76R per ml Q9963
MD Gastroview per ml Q9963
Mecasermin 1 mg SC J2170
Mechlorethamine HCl (nitrogen 10 mg IV J9230
mustard), HN2

Medralone 40 20 mg IM J1020
40 mg IM J1030
 80 mg IM J1040
Medralone 80 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
Medrol per 4 mg ORAL J7509
Medroxyprogesterone acetate 1 mg IM J1050
Mefoxin 1g IV, IM J0694
Megestrol Acetate J8999
Meloxicam 1 mg IV J1738
Melphalan (evomela) 1 mg IV J9246
Melphanlan flufenamide 1 mg IV J9247
Melphalan HCl 50 mg IV J9245
Melphalan, oral 2 mg ORAL J8600
Menoject LA 1 mg J1071
Mepergan injection up to 50 mg IM, IV J2180
Meperidine and promethazine up to 50 mg IM, IV J2180
HCl
Meperidine HCl per 100 mg IM, IV, SC J2175
Mepivacaine HCl per 10 ml VAR J0670
Mepolizumab 1 mg IV J2182
Mercaptopurine J8999
Meropenem 100 mg IV J2184, ◀
J2185
Merrem 100 mg J2185
Mesna 200 mg IV J9209
Mesnex 200 mg IV J9209
Metaprel
concentrated form per 10 mg INH J7667,
J7668
 unit dose form per 10 mg INH J7669,
J7670
Metaproterenol sulfate
concentrated form per 10 mg INH J7667,
J7668
unit dose form per 10 mg INH J7669,
J7670
Metaraminol bitartrate per 10 mg IV, IM, SC J0380
Metastron per millicurie A9600
Methacholine chloride 1 mg INH J7674
Methadone HCl up to 10 mg IM, SC J1230
Methergine up to 0.2 mg J2210
Methocarbamol up to 10 ml IV, IM J2800
Methotrexate LPF 5 mg IV, IM, IT, J9250
IA
50 mg IV, IM, IT, J9260
IA
Methotrexate, oral 2.5 mg ORAL J8610
Methotrexate sodium 5 mg IV, IM, IT, J9250
IA
50 mg IV, IM, IT, J9260
IA
Methyldopate HCl up to 250 mg IV J0210
Methylergonovine maleate up to 0.2 mg J2210
Methylnaltrexone 0.1 mg SC J2212
Methylprednisolone acetate 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
Methylprednisolone, oral per 4 mg ORAL J7509
Methylprednisolone sodium up to 40 mg IM, IV J2920
succinate
 up to 125 mg IM, IV J2930
Metoclopramide HCl up to 10 mg IV J2765
Metrodin 75 IU J3355
Metronidazole J3490
Metvixia 1g OTH J7309
Miacalcin up to 400 units SC, IM J0630
Micafungin sodium 1 mg J2247, ◀
J2248
MicRhoGAM 50 mcg J2788
Midazolam HCl per 1 mg IM, IV J2250, ◀
J2251
Milrinone lactate 5 mg IV J2260
Minocine 1 mg J2265
Minocycline Hydrochloride 1 mg IV J2265
Mircera 1 mcg J0887,
J0888
Mirena 52 mg OTH J7297,
J7298
Mithracin 2,500 mcg IV J9270
Mitomycin 0.2 mg Ophthalmic J7315
5 mg IV J9280
Mitosol 0.2 mg Ophthalmic J7315
5 mg IV J9280
Mitoxantrone HCl per 5 mg IV J9293
Mogamulizumab-kpkc 1 mg IV J9204
Mometasone furoate sinus 10 mcg OTH J7402
implant, (sinuva)

Monocid, see Cefonicic sodium

Monoclate-P
 human per IU IV J7190
porcine per IU IV J7191
Monoclonal antibodies, parenteral 5 mg IV J7505
Mononine per IU IV J7193
Monovisc J7327
Morphine sulfate up to 10 mg IM, IV, SC J2270, ◀
J2272
preservative-free 10 mg SC, IM, IV J2274
Moxetumomab Pasudotox-tdfk 0.01 mg IV J9313
Moxifloxacin 100 mg IV J2280, ◀
J2281
Mozobil 1 mg J2562
M-Prednisol-40 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
M-Prednisol-80 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
Mucomyst
unit dose form per gram INH J7604,
J7608
Mucosol
injection 100 mg IV J0132
unit dose per gram INH J7604,
J7608
MultiHance per ml A9577

MultiHance Multipack per ml A9578

Muromonab-CD3 5 mg IV J7505
Muse OTH J0275
 1.25 mcg OTH J0270
Mustargen 10 mg IV J9230
Mutamycin
0.2 mg Ophthalmic J7315
5 mg IV J9280
Mycamine 1 mg J2248
Mycophenolate Mofetil 250 mg ORAL J7517
Mycophenolic acid 180 mg ORAL J7518
Myfortic 180 mg J7518
Myleran 1 mg J0594
2 mg ORAL J8510
Mylotarg 5 mg IV J9300
Myobloc per 100 units IM J0587
Myochrysine up to 50 mg IM J1600
Myolin up to 60 mg IV, IM J2360
N
Nabilone 1 mg ORAL J8650
Nafcillin J3490
Naglazyme 1 mg J1458
Nalbuphine HCl per 10 mg IM, IV, SC J2300
Naloxone HCl per 1 mg IM, IV, SC J2310, ◀
J2311,
J3490
Naltrexone J3490
Naltrexone, depot form 1 mg IM J2315
Nandrobolic L.A. up to 50 mg IM J2320

Nandrolone decanoate up to 50 mg IM J2320

Narcan 1 mg IM, IV, SC J2310
Naropin 1 mg J2795
Nasahist B per 10 mg IM, SC, IV J0945
Nasal vaccine inhalation INH J3530
Natalizumab 1 mg IV J2323
Natrecor 0.1 mg J2325
Navane, see Thiothixene
Navelbine per 10 mg IV J9390
Naxitamab-gqgk 1 mg IV J9348
ND Stat per 10 mg IM, SC, IV J0945
Nebcin up to 80 mg IM, IV J3260
NebuPent per 300 mg INH J2545,
J7676
Necitumumab 1 mg IV J9295
Nelarabine 50 mg IV J9261
Nembutal Sodium Solution per 50 mg IM, IV, J2515
OTH
Neocyten up to 60 mg IV, IM J2360
Neo-Durabolic up to 50 mg IM J2320
Neoquess up to 20 mg IM J0500
Neoral 100 mg J7502
25 mg J7515
Neosar 100 mg IV J9070
Neostigmine methylsulfate up to 0.5 mg IM, IV, SC J2710
Neo-Synephrine up to 1 ml SC, IM, IV J2370
Nervocaine 1% 10 mg IV J2001
Nervocaine 2% 10 mg IV J2001
Nesacaine per 30 ml VAR J2400 ✖
Nesacaine-MPF per 30 ml VAR J2400 ✖
Nesiritide 0.1 mg IV J2325
Netupitant 300 mg and ORAL J8655
palonosetron 0.5 mg
Neumega 5 mg SC J2355
Neupogen
(G-CSF) 1 mcg SC, IV J1442
Neutrexin per 25 mg IV J3305
Nipent per 10 mg IV J9268
Nivol relatlimab 3mg/1mg IM J9298 ◀
Nivolumab 1 mg IV J9299
Nolvadex J8999
Nordryl up to 50 mg IV, IM J1200
50 mg ORAL Q0163
Norflex up to 60 mg IV, IM J2360
Norzine up to 10 mg IM J3280
Not otherwise classified drugs J3490
other than inhalation solution J7799
administered through DME
inhalation solution J7699
administered through DME
anti-neoplastic J9999
chemotherapeutic ORAL J8999
immunosuppressive J7599
nonchemotherapeutic ORAL J8499
Novantrone per 5 mg IV J9293
Novarel per 1,000 USP J0725
Units

Novolin per 5 units J1815

per 50 units J1817
Novolog per 5 units J1815
 per 50 units J1817
Novo Seven 1 mcg IV J7189
Novoeight J7182
NPH 5 units SC J1815
Nplate 100 units J0587
10 mcg J2796
Nubain per 10 mg IM, IV, SC J2300
Nulecit 12.5 mg J2916
Nulicaine 10 mg IV J2001
Nulojix 1 mg IV J0485
Numorphan up to 1 mg IV, SC, IM J2410
Numorphan H.P. up to 1 mg IV, SC, IM J2410
Nusinersen 0.1 mg IV J2326
Nutropin 1 mg J2941
O
Oasis Burn Matrix per square Q4103
centimeter
Oasis Wound Matrix per square Q4102
centimeter
Obinutuzumab 10 mg J9301
Ocriplasmin 0.125 mg IV J7316
Ocrelizumab 1 mg IV J2350
Octagam 500 mg IV J1568
Octreotide Acetate, injection 1 mg IM J2353
25 mcg IV, SQ J2354
Oculinum per unit IM J0585
Ofatumumab 10 mg IV J9302
Ofev J8499
Ofirmev 10 mg IV J0131
O-Flex up to 60 mg IV, IM J2360
Oforta 10 mg J8562
Olanzapine 1 mg IM J2358
Olaratumab 10 mg IV J9285
Omadacycline 1 mg IV J0121
Omacetaxine Mepesuccinate 0.01 mg IV J9262
Omalizumab 5 mg SC J2357
Omnipaque per ml Q9965,
Q9966,
Q9967
Omnipen-N up to 500 mg IM, J0290
IV
per 1.5 gm IM, J0295
IV
Omniscan per ml A9579
Omnitrope 1 mg J2941
Omontys 0.1 mg IV, SC J0890
OnabotulinumtoxinA 1 unit IM J0585
Onasemnogene abeparvovec-xioi, up to 5x10 15 IM J3399
per treatment, vector genomes
Oncaspar per single dose IM, J9266
vial IV
Oncovin 1 mg IV J9370
Ondansetron HCI 1 mg IV J2405
1 mg ORAL Q0162
Onivyde 1 mg J9205
Opana up to 1 mg J2410
Opdivo 1 mg J9299
Oprelvekin 5 mg SC J2355
Optimark per ml A9579
Optiray per ml Q9966,
Q9967
Optison per ml Q9956
Oraminic II per 10 mg IM, J0945
SC,
IV
Orapred per 5 mg ORAL J7510
Orbactiv 10 mg J2407
Orencia 10 mg J0129
Oritavancin (kimyrsa) 10 mg IV J2406
Oritavancin (orbactiv) 10 mg IV J2407
Ormazine up to 50 mg IM, J3230
IV
Orphenadrine citrate up to 60 mg IV, IM J2360
Orphenate up to 60 mg IV, IM J2360
Orthovisc OTH J7324
Or-Tyl up to 20 mg IM J0500
Osmitrol J7799
Ovidrel J3490
Oxacillin sodium up to 250 mg IM, J2700
IV
Oxaliplatin 0.5 mg IV J9263
Oxilan per ml Q9967
Oxymorphone HCl up to 1 mg IV, J2410
SC,
IM
Oxytetracycline HCl up to 50 mg IM J2460
Oxytocin up to 10 units IV, IM J2590
Ozurdex 0.1 mg J7312
P
Paclitaxel 1 mg IV J9267
Paclitaxel protein-bound particles 1 mg IV J9264
Palifermin 50 mcg IV J2425
Paliperidone palmitate 1 mg IM J2426
Palonosetron HCl 25 mcg IV J2469
Netupitant 300 mg and ORAL J8655
palonosetron 0.5 mg
Pamidronate disodium per 30 mg IV J2430
Panhematin 1 mg J1640
Panitumumab 10 mg IV J9303
Papaverine HCl up to 60 mg IV, IM J2440
Paragard T 380 A OTH J7300
Paraplatin 50 mg IV J9045
Paricalcitol, injection 1 mcg IV, IM J2501
Pasireotide, long acting 1 mg IV J2502
Pathogen(s) test for platelets OTH P9100
Patisiran 0.1 mg IV J0222
Peforomist 20 mcg J7606
Pegademase bovine 25 IU J2504
Pegaptinib 0.3 mg OTH J2503
Pegaspargase per single dose IM, J9266
vial IV
Pegasys J3490
Pegfilgrastim-bmez, biosimilar, 0.5 mg IM Q5120
(ziextenzo)
Pegfilgrastim-jmdb 0.5 mg SC Q5108
Peginesatide 0.1 mg IV, SC J0890
Peg-Intron J3490
Pegloticase 1 mg IV J2507
Pembrolizumab 1 mg IV J9271
Pemetrexed 10 mg IV J9305
Pemetrexed (Pemfexy) 10 mg IV J9304
Penicillin G Benzathine 100,000 units IM J0561
Penicillin G Benzathine and 100,000 units IM J0558
Penicillin G Procaine
Penicillin G potassium up to 600,000 IM, J2540
units IV
Penicillin G procaine, aqueous up to 600,000 IM, J2510
units IV
Penicillin G Sodium J3490
Pentam per 300 mg J7676
Pentamidine isethionate per 300 mg INH, J2545, J7676
IM
Pentastarch, 10% 100 ml J2513
Pentazocine HCl 30 mg IM, J3070
 SC,
IV

Pentobarbital sodium per 50 mg IM, J2515

IV,
OTH
Pentostatin per 10 mg IV J9268
Peramivir 1 mg IV J2547
Perjeta 1 mg J9306
Permapen up to 600,000 IM J0561
Perphenazine
injection up to 5 mg IM, J3310
IV
tablets 4 mg ORAL Q0175
Persantine IV per 10 mg IV J1245
Pertuzumab 1 mg IV J9306
Pet Imaging
Fluciclovine F-18, diagnostic 1 millcurie IV A9588
Gallium Ga-68, dotatate, 0.1 millicurie IV A9587
diagnostic
Gallium ga-68, psma-11, (ucla) 1 millicurie IV A9594
Gallium ga-68, psma-11, (ucsf) 1 millicurie IV A9593
Pfizerpen up to 600,000 IM, J2540
units IV
Pfizerpen A.S. up to 600,000 IM, J2510
units IV
Phenadoz J8498
Phenazine 25 up to 50 mg IM, J2550
IV
12.5 mg ORAL Q0169
Phenazine 50 up to 50 mg IM, J2550
IV
 12.5 mg ORAL Q0169

Phenergan 12.5 mg ORAL Q0169

up to 50 mg IM, J2550
IV
J8498
Phenobarbital sodium up to 120 mg IM, J2560
IV
Phentolamine mesylate up to 5 mg IM, J2760
IV
Phenylephrine HCl up to 1 ml SC, J2370, J7799
IM,
IV
Phenylephrine 10.16 mg/Ketorolac 1 ml VAR J1097
2.88
Phenytoin sodium per 50 mg IM, J1165
IV
Photofrin 75 mg IV J9600
Phytonadione (Vitamin K) per 1 mg IM, J3430
SC,
IV
Piperacillin/Tazobactam Sodium, 1.125 g IV J2543
injection
Pitocin up to 10 units IV, IM J2590
Plantinol AQ 10 mg IV J9060
Plasma
cryoprecipitate reduced each unit IV P9044
pooled multiple donor, frozen each unit IV P9023, P9070
(single donor), pathogen reduced, each unit IV P9071
frozen
Plasminogen TVMH 1 mg J2998 ◀
Plas+SD each unit IV P9023
Platelets, pheresis, pathogen reduced each unit IV P9073
 Pathogen(s) test for platelets OTH P9100
Platinol 10 mg IV, IM J9060
Plazomicin 5 mg IV J0291
Plerixafor 1 mg SC J2562
Plicamycin 2,500 mcg IV J9270
Polatuzumab vedotin 1 mg IV J9309
Polocaine per 10 ml VAR J0670
Polycillin-N up to 500 mg IM, J0290
IV
per 1.5 gm IM, J0295
IV
Polygam 500 mg J1566
Porfimer Sodium 75 mg IV J9600
Portrazza 1 mg J9295
Positron emission tomography
radiopharmaceutical, diagnostic
for non-tumor identification, NOC IV A9598
for tumor identification, NOC IV A9597
Potassium chloride per 2 mEq IV J3480
Potassium Chloride up to 1,000 cc J7120
Pralatrexate 1 mg IV J9307
Pralidoxime chloride up to 1 g IV, J2730
IM,
SC
Predalone-50 up to 1 ml IM J2650
Predcor-25 up to 1 ml IM J2650
Predcor-50 up to 1 ml IM J2650
Predicort-50 up to 1 ml IM J2650
Prednisolone acetate up to 1 ml IM J2650
Prednisolone, oral 5 mg ORAL J7510
Prednisone, immediate release or 1 mg ORAL J7512
delayed release
Predoject-50 up to 1 ml IM J2650
Pregnyl per 1,000 USP IM J0725
units
Premarin Intravenous per 25 mg IV, IM J1410
Prescription, chemotherapeutic, not ORAL J8999
otherwise specified
Prescription, nonchemotherapeutic, ORAL J8499
not otherwise specified
Prialt 1 mcg J2278
Primacor 5 mg IV J2260
Primatrix per square Q4110
centimeter
Primaxin per 250 mg IV, IM J0743
Priscoline HCl up to 25 mg IV J2670
Privigen 500 mg IV J1459
Probuphine System Kit J0570
Procainamide HCl up to 1 g IM, J2690
IV
Prochlorperazine up to 10 mg IM, J0780
IV
J8498
Prochlorperazine maleate 5 mg ORAL Q0164
5 mg S0183
Procrit J0885
Q4081
Pro-Depo, see Hydroxyprogesterone
Caproate

Profasi HP per 1,000 USP IM J0725

units
Profilnine Heat-Treated
non-recombinant per IU IV J7193
recombinant per IU IU J7195,
J7200-J7202
complex per IU IV J7194
Profonol 10 mg/ml J3490
Progestaject per 50 mg J2675
Progesterone per 50 mg IM J2675
Prograf
oral 1 mg ORAL J7507
parenteral 5 mg J7525
Prohance Multipack per ml A9576
Prokine 50 mcg IV J2820
Prolastin 10 mg IV J0256
Proleukin per single use vial IM, J9015
IV
Prolia 1 mg J0897
Prolixin Decanoate up to 25 mg IM, J2680
SC
Promazine HCl up to 25 mg IM J2950
Promethazine J8498
Promethazine HCl
injection up to 50 mg IM, J2550
IV
oral 12.5 mg ORAL Q0169
Promethegan J8498
Pronestyl up to 1 g IM, J2690
IV

Proplex SX-T
 non-recombinant per IU IV J7193
recombinant per IU J7195,
J7200-J7202
complex per IU IV J7194
Proplex T
non-recombinant per IU IV J7193
recombinant per IU J7195,
J7200-J7202
complex per IU IV J7194
Propofol 10 mg IV J2704
Propranolol HCl up to 1 mg IV J1800
Prorex-25
up to 50 mg IM, J2550
IV
12.5 mg ORAL Q0169
Prorex-50 up to 50 mg IM, J2550
IV
12.5 mg ORAL Q0169
Prostaglandin E1 per 1.25 mcg J0270
Prostaphlin up to 1 g IM, J2690
IV
Prostigmin up to 0.5 mg IM, J2710
IV, SC
Prostin VR Pediatric 0.5 mg J0270
Protamine sulfate per 10 mg IV J2720
Protein C Concentrate 10 IU IV J2724
Prothazine up to 50 mg IM, J2550
IV

12.5 mg ORAL Q0169

Prothrombin complex concentrate per i.u. of factor OTH J7168
(human), kcentra ix activity
Protirelin per 250 mcg IV J2725
Protonix J3490
Protopam Chloride up to 1 g IV, J2730
IM,
SC
Provenge Q2043
Proventil
concentrated form 1 mg INH J7610, J7611
unit dose form 1 mg INH J7609, J7613
Provocholine per 1 mg J7674
Prozine-50 up to 25 mg IM J2950
Pulmicort Respules
concentrated form 0.25 mg INH J7633, J7634
unit dose 0.5 mg INH J7626, J7627
Pulmozyme per mg J7639
Pyridoxine HCl 100 mg J3415
Q
Quelicin up to 20 mg IV, IM J0330
Quinupristin/dalfopristin 500 mg (150/350) IV J2770
Qutenza per square cm J7336
R
Ramucirumab 5 mg IV J9308
Ranibizumab 0.1 mg OTH J2778
Ranitidine HCl, injection 25 mg IV, IM J2780
Rapamune 1 mg ORAL J7520
Rasburicase 0.5 mg IV J2783
Ravulizumab-cwvz 10 mg IV J1303
Rebif 11 mcg Q3026
Reclast 1 mg J3489
Recombinate
human per IU IV J7190
porcine per IU IV J7191
recombinant per IU IV J7192
Recombivax J3490
Redisol up to 1,000 mcg IM, J3420
SC
Regadenoson 0.1 mg IV J2785
Regitine up to 5 mg IM, J2760
IV
Reglan up to 10 mg IV J2765
Regular 5 units SC J1815
Relefact TRH per 250 mcg IV J2725
Relistor 0.1 mg SC J2212
Remicade 10 mg IM, J1745
IV
Remodulin 1 mg J3285
Renflexis Q5102
ReoPro 10 mg IV J0130
Rep-Pred 40 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
Rep-Pred 80 20 mg IM J1020

40 mg IM J1030
80 mg IM J1040
Resectisol J7799
Reslizumab 1 mg IV J2786
Retavase 18.1 mg IV J2993
Reteplase 18.8 mg IV J2993
Retisert J7311
Retrovir 10 mg IV J3485
Revefenacin inhalation solution — INH J7677
Rheomacrodex 500 ml IV J7100
Rhesonativ 300 mcg IM J2790
50 mg J2788
Rheumatrex Dose Pack 2.5 mg ORAL J8610
Rho(D)
immune globulin IM, J2791
IV
immune globulin, human 1 dose IM J2790
package/300 mcg
50 mg IM J2788
immune globulin, human, solvent 100 IV, IU J2792
detergent
RhoGAM 300 mcg IM J2790
50 mg J2788
Rhophylac 100 IU IM, J2791
IV
Riastap 100 mg J7178
Rifadin J3490
Rifampin J3490
Rilonacept 1 mg SC J2793

RimabotulinumtoxinB 100 units IM J0587

Rimso-50 50 ml J1212
Ringers lactate infusion up to 1,000 cc IV J7120, J7121
Risankizumab 1 mg IV J2327 ◀
Risperdal Consta 0.5 mg J2794
Risperidone 0.5 mg IM J2794
Risperidone (perseris) 0.5 mg IV J2798
Rituxan 100 mg IV J9312
Rituximab 100 mg IV J9312
Rituximab-abbs 10 mg IV Q5115
Rituximab-arrx, biosimilar, (riabni) 10 mg IV Q5123
Rituximab-pvvr, biosimilar, 10 mg IV Q5119
(Ruxience)
Rixubis J7200
Robaxin up to 10 ml IV, IM J2800
Rocephin per 250 mg IV, IM J0696
Roferon-A 3 million units SC, J9213
IM
Rolapitant 0.5 mg IV J2797
Rolapitant, oral, 1 mg 1 mg ORAL J8670
Romidepsin lyophilized 1 mg IV J9319
Romidepsin, non-lyophilized 0.1 mg IV J9318
Romiplostim 10 mcg SC J2796
Romosozumab-aqqg 1 mg IV J3111
Ropivacaine Hydrochloride 1 mg OTH J2795
Rubex 10 mg IV J9000
Rubramin PC up to 1,000 mcg IM, J3420
SC

S
Saizen 1 mg J2941
Saline solution 10 ml A4216
5% dextrose 500 ml IV J7042
infusion 250 cc IV J7050
1,000 cc IV J7030
sterile 500 ml = 1 unit IV, J7040
 OTH
Sandimmune 25 mg ORAL J7515
100 mg ORAL J7502
250 mg OTH J7516
Sandoglobulin, see Immune globulin
intravenous (human)
Sandostatin, Lar Depot 25 mcg J2354
1 mg IM J2353
Sargramostim (GM-CSF) 50 mcg IV J2820
Sculptra 0.5 mg IV Q2028
Sebelelipase alfa 1 mg IV J2840
Selestoject per 4 mg IM, J0702
IV
Sermorelin acetate 1 mcg SC Q0515
Serostim 1 mg J2941
Signifor LAR 20 ml J2502
Siltuximab 10 mg IV J2860
Simponi Aria 1 mg J1602
Simulect 20 mg J0480
Sincalide 5 mcg IV J2805
Sinografin per ml Q9963
Sinusol-B per 10 mg IM, J0945
SC,
IV

Sirolimus 1 mg ORAL J7520

Sirolimus protien-bound 1 mg IM J9331 ◀
Sivextro 1 mg J3090
Skyla 13.5 mg OTH J7301
Smz-TMP J3490
Sodium Chloride 1,000 cc J7030
500 ml = 1 unit J7040
500 ml A4217
250 cc J7050
Bacteriostatic 10 ml A4216
Sodium Chloride Concentrate J7799
Sodium ferricgluconate in sucrose 12.5 mg J2916
Sodium Hyaluronate J3490
Euflexxa J7323
Hyalgan J7321
Orthovisc J7324
Solganal up to 50 mg IM J2910
Soliris 10 mg J1300
Solu-Cortef up to 50 mg IV, J1710
IM,
SC
100 mg J1720
Solu-Medrol up to 40 mg IM, J2920
IV
up to 125 mg IM, J2930
IV
Solurex 1 mg IM, J1100
IV,
OTH

Solurex LA 1 mg IM J1094
Somatrem 1 mg SC J2940
Somatropin 1 mg SC J2941
Somatulin Depot 1 mg J1930
Sparine up to 25 mg IM J2950
Spasmoject up to 20 mg IM J0500
Spectinomycin HCl up to 2 g IM J3320
Sporanox 50 mg IV J1835
Staphcillin, see Methicillin sodium
Stelara 1 mg J3357
Stilphostrol 250 mg IV J9165
Streptase 250,000 IU IV J2995
Streptokinase per 250,000 IU, IV J2995
Streptomycin up to 1 g IM J3000
Streptomycin Sulfate up to 1 g IM J3000
Streptozocin 1 gm IV J9320
Strontium-89 chloride per millicurie A9600
Sublimaze 0.1 mg IM, J3010
IV
Succinylcholine chloride up to 20 mg IV, IM J0330
Sufentanil Citrate J3490
Sumarel Dosepro 6 mg J3030
Sumatriptan succinate 6 mg SC J3030
Supartz OTH J7321
Supprelin LA 50 mg J9226
Surostrin up to 20 mg IV, IM J0330
Sus-Phrine up to 1 ml ampule SC, J0171
IM
Sutimlimab-jome 10 mg IM J1302 ◀
Susvimo 0.1 mg J2779 ◀
Synercid 500 mg (150/350) IV J2770
Synkavite per 1 mg IM, J3430
SC,
IV
Synribo 0.01 mg J9262
Syntocinon up to 10 units IV, IM J2590
Synvisc and Synvisc-One 1 mg OTH J7325
Syrex 10 ml A4216
Sytobex 1,000 mcg IM, J3420
SC
T
Tacrolimus
(Envarsus XR) 0.25 mg ORAL J7503
oral, extended release 0.1 mg ORAL J7508
oral, immediate release 1 mg ORAL J7507
parenteral 5 mg IV J7525
Tafasitamab 2 mg IV J9349
Tagraxofusp-erzs 10 mcg IV J9269
Taliglucerase Alfa 10 units IV J3060
Talimogene laherparepvec per 1 million IV J9325
plaque forming
units
Talwin 30 mg IM, J3070
SC,
IV
Tamoxifen Citrate J8999
Taractan, see Chlorprothixene
Taxol 1 mg IV J9267
Taxotere 20 mg IV J9171
Tazicef per 500 mg J0713
Tazidime, see Ceftazidime per dose A9500
Technetium TC Sestambi
J0713
Tebentafusp-tebn 1 mcg IM J9274 ◀
Tedizolid phosphate 1 mg IV J3090
TEEV 1 mg IM J3121
Teflaro 1 mg J0712
Telavancin 10 mg IV J3095
Temodar 5 mg ORAL J8700, J9328
Temozolomide 1 mg IV J9328
5 mg ORAL J8700
Temsirolimus 1 mg IV J9330
Tenecteplase 1 mg IV J3101
Teniposide 50 mg Q2017
Tepadina 15 mg J9340
Teprotumumab-trbw 10 mg IV J3241
Tequin 10 mg IV J1590
Terbutaline sulfate up to 1 mg SC, J3105
IV
concentrated form per 1 mg INH J7680
unit dose form per 1 mg INH J7681
Teriparatide 10 mcg SC J3110
Terramycin IM up to 50 mg IM J2460
Testa-C 1 mg J1071
Testadiate 1 mg IM J3121
Testadiate-Depo 1 mg J1071
Testaject-LA 1 mg J1071

Testaqua up to 50 mg IM J3140
Test-Estro Cypionates 1 mg J1071
Test-Estro-C 1 mg J1071
Testex up to 100 mg IM J3150
Testo AQ up to 50 mg J3140
Testoject-50 up to 50 mg IM J3140
Testoject-LA 1 mg J1071
Testone
LA 100 1 mg IM J3121
LA 200 1 mg IM J3121
Testopel Pellets J3490
Testosterone Aqueous up to 50 mg IM J3140
Testosterone cypionate 1 mg IM J1071
Testosterone enanthate 1 mg IM J3121
Testosterone undecanoate 1 mg IM J3145
Testradiol 90/4 1 mg IM J3121
Testrin PA 1 mg IM J3121
Testro AQ up to 50 mg J3140
Tetanus immune globulin, human up to 250 units IM J1670
Tetracycline up to 250 mg IM, J0120
IV
Tezepelumab-ekko 1 mg J2356 ◀
Thallous Chloride TI-201 per MCI A9505
Theelin Aqueous per 1 mg IM J1435
Theophylline per 40 mg IV J2810
Thiamine HCl 100 mg J3411
Thiethylperazine maleate
injection up to 10 mg IM J3280
oral 10 mg ORAL Q0174
Thiotepa 15 mg IV J9340
Thorazine up to 50 mg IM, J3230
IV
Thrombate III per IU J7197
Thymoglobulin (see also Immune
globulin)
anti-thymocyte globulin, equine 250 mg IV J7504
 anti-thymocyte globulin, rabbit 25 mg IV J7511
Thypinone per 250 mcg IV J2725
Thyrogen 0.9 mg IM, J3240
SC
Thyrotropin Alfa, injection 0.9 mg IM, J3240
SC
Ticon
injection up to 200 mg IM J3250
oral 250 mg ORAL Q0173
Tigan
injection up to 200 mg IM J3250
oral 250 mg ORAL Q0173
Tigecycline 1 mg IV J3243, J3244 ◀
Tiject-20
injection up to 200 mg IM J3250
oral 250 mg ORAL Q0173
Tinzaparin 1,000 IU SC J1655
Tirofiban Hydrochloride, injection 0.25 mg IM, J3246
IV
TNKase 1 mg IV J3101
Tobi 300 mg INH J7682, J7685
Tobramycin, inhalation solution 300 mg INH J7682, J7685
Tobramycin sulfate up to 80 mg IM, J3260
IV
Tocilizumab 1 mg IV J3262
Tofranil, see Imipramine HCl
Tolazoline HCl up to 25 mg IV J2670
Toposar 10 mg J9181
Topotecan 0.25 mg ORAL J8705
0.1 mg IV J9351
Toradol per 15 mg IM, J1885
IV
Torecan
injection up to 10 mg IM J3280
oral 10 mg ORAL Q0174
Torisel 1 mg J9330
Tornalate
concentrated form per mg INH J7628
unit dose per mg INH J7629
Torsemide 10 mg/ml IV J3265
Totacillin-N up to 500 mg IM, J0290
IV
per 1.5 gm IM, J0295
IV
Trabectedin 0.1 mg IV J9352
Trastuzumab 10 mg IV J9355
Trastuzumab-anns (kanjinti) 10 mg IV Q5117
Trastuzumab-dkst 10 mg IV Q5114
Trastuzumab-dttb 10 mg IV Q5112

Trastuzumab-pkrb 10 mg IV Q5113
Trastuzumab-qyyp (trazimera) 10 mg IV Q5116
Trastuzumab and Hyaluronidase 10 mg IV J9356
Treanda 1 mg IV J3490, J9033
Trelstar 3.75 mg J3315
Treprostinil 1 mg J3285, J7686
Trexall 2.5 mg ORAL J8610
Triam-A 1 mg J3300
per 10 mg IM J3301
Triamcinolone
 concentrated form per 1 mg INH J7683
unit dose per 1 mg INH J7684
Triamcinolone acetonide 1 mg J3300
per 10 mg IM J3301
Triamcinolone acetonide XR 1 mg IM J3304
Triamcinolone diacetate per 5 mg IM J3302
Triamcinolone hexacetonide per 5 mg VAR J3303
Triesence 1 mg J3300
per 10 mg IM J3301
Triethylene thio-Phosphoramide/T 15 mg J9340
Triflupromazine HCl up to 20 mg IM, J3400
IV
Tri-Kort 1 mg J3300
per 10 mg IM J3301
Trilaciclib 1 mg IV J1448
Trilafon 4 mg ORAL Q0175

up to 5 mg IM, J3310
IV
Trilog 1 mg J3300
per 10 mg IM J3301
Trilone per 5 mg J3302
Trimethobenzamide HCl
injection up to 200 mg IM J3250
oral 250 mg ORAL Q0173
Trimetrexate glucuronate per 25 mg IV J3305
Triptorelin Pamoate 3.75 mg SC J3315
Triptorelin XR 3.75 mg SC J3316
Trisenox 1 mg IV J9017
Trobicin up to 2 g IM J3320
Trovan 100 mg IV J0200
Tysabri 1 mg J2323
Tyvaso 1.74 mg J7686
U
Ultravist 240 per ml Q9966
Ultravist 300 per ml Q9967
Ultravist 370 per ml Q9967
Ultrazine-10 up to 10 mg IM, J0780
IV
Unasyn per 1.5 gm IM, J0295
IV
Unclassified drugs (see also Not J3490
elsewhere classified)
Unclassified drugs or biological used IV J3591
for ESRD on dialysis
Unspecified oral antiemetic Q0181
Urea up to 40 g IV J3350

Ureaphil up to 40 g IV J3350
Urecholine up to 5 mg SC J0520
Urofollitropin 75 IU J3355
Urokinase 5,000 IU vial IV J3364
250,000 IU vial IV J3365
Ustekinumab 1 mg SC J3357
1 mg IV J3358
V
Valcyte J3490
Valergen 10 10 mg IM J1380
Valergen 20 10 mg IM J1380
Valergen 40 up to 10 mg IM J1380
Valertest No. 1 1 mg IM J3121
Valertest No. 2 1 mg IM J3121
Valganciclovir HCL J8499
Valium up to 5 mg IM, J3360
IV
Valrubicin, intravesical 200 mg OTH J9357
Valstar 200 mg OTH J9357
Vancocin 500 mg IV, IM J3370
Vancoled 500 mg IV, IM J3370
Vancomycin HCl 500 mg IV, IM J3370, J3371, ◀
J3372
Vantas 50 mg J9226, J9225
Varubi 90 mg J8670
Vasceze per 10 mg J1642
Vasoxyl, see Methoxamine HCl
Vectibix 10 mg J9303
Vedolizumab 1 mg IV J3380
Velaglucerase alfa 100 units IV J3385
Velban 1 mg IV J9360
Velcade 0.1 mg J9041
Veletri 0.5 mg J1325
Velsar 1 mg IV J9360
Venofer 1 mg IV J1756
Ventavis 20 mcg Q4074
Ventolin 0.5 mg INH J7620
concentrated form 1 mg INH J7610, J7611
unit dose form 1 mg INH J7609, J7613
VePesid 50 mg ORAL J8560
Veritas Collagen Matrix J3490
Versed per 1 mg IM, J2250
IV
Verteporfin 0.1 mg IV J3396
Vesprin up to 20 mg IM, J3400
IV
Vestronidase alfa-vjbk 1 mg IV J3397
VFEND IV 10 mg IV J3465
V-Gan 25 up to 50 mg IM, J2550
IV
12.5 mg ORAL Q0169
V-Gan 50 up to 50 mg IM, J2550
IV
12.5 mg ORAL Q0169
Viadur 65 mg OTH J9219
Vibativ 10 mg J3095

Viltolarsen 10 mg IV J1427
Vinblastine sulfate 1 mg IV J9360
Vincasar PFS 1 mg IV J9370
Vincristine sulfate 1 mg IV J9370
Vincristine sulfate liposome 1 mg IV J9371
Vinorelbine tartrate per 10 mg IV J9390
Vispaque per ml Q9966,
Q9967
Vistaject-25 up to 25 mg IM J3410
Vistaril up to 25 mg IM J3410
25 mg ORAL Q0177
Vistide 375 mg IV J0740
Visudyne 0.1 mg IV J3396
Vitamin B-12 cyanocobalamin up to 1,000 mcg IM, J3420
 SC
Vitamin K, phytonadione, per 1 mg IM, J3430
menadione, menadiol sodium SC,
diphosphate IV
Vitrase per 1 USP unit J3471
Vivaglobin 100 mg J1562
Vivitrol 1 mg J2315
Von Willebrand Factor Complex, per IU VWF:RCo IV J7187
human
Wilate per IU VWF IV J7183
Vonvendi per IU VWF IV J7179
Voretigene neparvovec-rzyl 1 billion vector IV J3398
genomes
Voriconazole 10 mg IV J3465
Vpriv 100 units J3385
W
Wehamine up to 50 mg IM, J1240
IV
Wehdryl up to 50 mg IM, J1200
IV
50 mg ORAL Q0163
Wellcovorin per 50 mg IM, J0640
IV
Wilate per IU IV J7183
Win Rho SD 100 IU IV J2792
Wyamine Sulfate, see
Mephentermine sulfate
Wycillin up to 600,000 IM, J2510
units IV
Wydase up to 150 units SC, J3470
IV
X
Xeloda 150 mg ORAL J8520
500 mg ORAL J8521
Xeomin 1 unit J0588
Xgera 1 mg J0987
Xgeva 1 mg J0897
Xiaflex 0.01 mg J0775
Xipere 1 mg J3299 ◀
Xolair 5 mg J2357
Xopenex 0.5 mg INH J7620
concentrated form 1 mg INH J7610, J7611,
J7612
unit dose form 1 mg INH J7609, J7613,
J7614
Xylocaine HCl 10 mg IV J2001

Xyntha per IU IV J7185, J7192,

J7182, J7188
Y
Yervoy, see Ipilimumab
Yondelis 0.1 mg J9352, J9999
Z
Zaltrap 1 mg J9400
Zanosar 1g IV J9320
Zantac 25 mg IV, IM J2780
Zarxio 1 mcg Q5101
Zemaira 10 mg IV J0256
Zemplar 1 mcg IM, J2501
IV
Zenapax 25 mg IV J7513
Zerbaxa 1 gm J0695
Zetran up to 5 mg IM, J3360
IV
Ziconotide 1 mcg OTH J2278
Zidovudine 10 mg IV J3485
Zinacef per 750 mg IM, J0697
IV
Zinecard per 250 mg J1190
Ziprasidone Mesylate 10 mg IM J3486
Zithromax 1 gm ORAL Q0144
injection 500 mg IV J0456
Ziv-Aflibercept 1 mg IV J9400
Zmax 1g Q0144
Zofran 1 mg IV J2405

1 mg ORAL Q0162
Zoladex per 3.6 mg SC J9202
Zoledronic Acid 1 mg IV J3489
Zolicef 500 mg IV, IM J0690
Zometra 1 mg J3489
Zorbtive 1 mg J2941
Zortress 0.25 mg ORAL J7527
Zosyn 1.125 g IV J2543
Zovirax 5 mg J8499
Zyprexa Relprevv 1 mg J2358
Zyvox 200 mg IV J2020

◀ New Revised ✔ Reinstated deleted Deleted

 LEVEL II NATIONAL CODES
2023 HCPCS quarterly updates available on the companion
website at: http://www.codingupdates.com

DISCLAIMER
Every effort has been made to make this text complete and accurate, but no
guarantee, warranty, or representation is made for its accuracy or completeness.
This text is based on the Centers for Medicare and Medicaid Services Healthcare
Common Procedure Coding System (HCPCS).
Do not report HCPCS modifiers with MIPS CPT Category II codes, rather, use
Performance Measurement Modifiers 1P, 2P, 3P, and 8P, as instructed in the CPT
guidelines for Category II codes under ‘Modifiers’.

LEVEL II NATIONAL MODIFIERS

✽ A1 Dressing for one wound
✽ A2 Dressing for two wounds
✽ A3 Dressing for three wounds
✽ A4 Dressing for four wounds
✽ A5 Dressing for five wounds
✽ A6 Dressing for six wounds
✽ A7 Dressing for seven wounds
✽ A8 Dressing for eight wounds
✽ A9 Dressing for nine or more wounds
❂ AA Anesthesia services performed personally by anesthesiologist
IOM: 100-04, 12, 90.4
▶ AB Audiology service furnished personally by an audiologist without
a physician/npp order for non-acute hearing assessment unrelated
to disequilibrium, or hearing aids, or examinations for the
purpose of prescribing, fitting, or changing hearing aids; service
may be performed once every 12 months, per beneficiary
❂ AD Medical supervision by a physician: more than four concurrent
anesthesia procedures
IOM: 100-04, 12, 90.4
✽ AE Registered dietician
✽ AF Specialty physician
✽ AG Primary physician
❂ AH Clinical psychologist
IOM: 100-04, 12, 170
✽ AI Principal physician of record
❂ AJ Clinical social worker
IOM: 100-04, 12, 170; 100-04, 12, 150
✽ AK Nonparticipating physician
❂ AM Physician, team member service
Not assigned for Medicare
Cross Reference QM
✽ AO Alternate payment method declined by provider of service
✽ AP Determination of refractive state was not performed in the course
of diagnostic ophthalmological examination
✽ AQ Physician providing a service in an unlisted health professional
shortage area (HPSA)
✽ AR Physician provider services in a physician scarcity area
✽ AS Physician assistant, nurse practitioner, or clinical nurse specialist
services for assistant at surgery
✽ AT Acute treatment (this modifier should be used when reporting
service 98940, 98941, 98942)
✽ AU Item furnished in conjunction with a urological, ostomy, or
tracheostomy supply
✽ AV Item furnished in conjunction with a prosthetic device, prosthetic
or orthotic
✽ AW Item furnished in conjunction with a surgical dressing
✽ AX Item furnished in conjunction with dialysis services
✽ AY Item or service furnished to an ESRD patient that is not for the
treatment of ESRD
AZ Physician providing a service in a dental health professional
shortage area for the purpose of an electronic health record
incentive payment
✽ BA Item furnished in conjunction with parenteral enteral nutrition
(PEN) services
✽ BL Special acquisition of blood and blood products
✽ BO Orally administered nutrition, not by feeding tube
✽ BP The beneficiary has been informed of the purchase and rental
options and has elected to purchase the item
✽ BR The beneficiary has been informed of the purchase and rental
options and has elected to rent the item
✽ BU The beneficiary has been informed of the purchase and rental
options and after 30 days has not informed the supplier of his/her
decision
✽ CA Procedure payable only in the inpatient setting when performed
emergently on an outpatient who expires prior to admission
✽ CB Service ordered by a renal dialysis facility (RDF) physician as
part of the ESRD beneficiary’s dialysis benefit, is not part of the
composite rate, and is separately reimbursable
✽ CC Procedure code change (Use CC when the procedure code
submitted was changed either for administrative reasons or
because an incorrect code was filed)
❂ CD AMCC test has been ordered by an ESRD facility or MCP
physician that is part of the composite rate and is not separately
billable
❂ CE AMCC test has been ordered by an ESRD facility or MCP
physician that is a composite rate test but is beyond the normal
frequency covered under the rate and is separately reimbursable
based on medical necessity
❂ CF AMCC test has been ordered by an ESRD facility or MCP
physician that is not part of the composite rate and is separately
billable
✽ CG Policy criteria applied
❂ CH 0 percent impaired, limited or restricted
❂ CI At least 1 percent but less than 20 percent impaired, limited or
restricted
❂ CJ At least 20 percent but less than 40 percent impaired, limited or
restricted
❂ CK At least 40 percent but less than 60 percent impaired, limited or
restricted
❂ CL At least 60 percent but less than 80 percent impaired, limited or
restricted
❂ CM At least 80 percent but less than 100 percent impaired, limited or
restricted
❂ CN 100 percent impaired, limited or restricted
✽ CO Outpatient occupational therapy services furnished in whole or in
part by an occupational therapy assistant
✽ CR Catastrophe/Disaster related
✽ CS Cost-sharing waived for specified covid-19 testing-related
services that result in and order for or administration of a covid-
19 test and/or used for cost-sharing waived preventive services
 furnished via telehealth in rural health clinics and federally
qualified health centers during the covid-19 public health
emergency
✽ CT Computed tomography services furnished using equipment that
does not meet each of the attributes of the national electrical
manufacturers association (NEMA) XR-29-2013 standard
Coding Clinic: 2017, Q1, P6
✽ CQ Outpatient physical therapy services furnished in whole or in part
by a physical therapist assistant
✽ DA Oral health assessment by a licensed health professional other
than a dentist
✽ E1 Upper left, eyelid
Coding Clinic: 2016, Q3, P3
✽ E2 Lower left, eyelid
Coding Clinic: 2016, Q3, P3
✽ E3 Upper right, eyelid
Coding Clinic: 2011, Q3, P6
✽ E4 Lower right, eyelid
❂ EA Erythropoetic stimulating agent (ESA) administered to treat
anemia due to anti-cancer chemotherapy
CMS requires claims for non-ESRD ESAs (J0881 and J0885) to
include one of three modifiers: EA, EB, EC.
❂ EB Erythropoetic stimulating agent (ESA) administered to treat
anemia due to anti-cancer radiotherapy
CMS requires claims for non-ESRD ESAs (J0881 and J0885) to
include one of three modifiers: EA, EB, EC.
❂ EC Erythropoetic stimulating agent (ESA) administered to treat
anemia not due to anti-cancer radiotherapy or anti-cancer
chemotherapy
CMS requires claims for non-ESRD ESAs (J0881 and J0885) to
include one of three modifiers: EA, EB, EC.
❂ ED Hematocrit level has exceeded 39% (or hemoglobin level has
exceeded 13.0 g/dl) for 3 or more consecutive billing cycles
immediately prior to and including the current cycle
❂ EE Hematocrit level has not exceeded 39% (or hemoglobin level has
not exceeded 13.0 g/dl) for 3 or more consecutive billing cycles
immediately prior to and including the current cycle
❂ EJ Subsequent claims for a defined course of therapy, e.g., EPO,
 sodium hyaluronate, infliximab
❂ EM Emergency reserve supply (for ESRD benefit only)
✽ EP Service provided as part of Medicaid early periodic screening
diagnosis and treatment (EPSDT) program
✽ ER Items and services furnished by a provider-based, off-campus
emergency department
✽ ET Emergency services
✽ EX Expatriate beneficiary
✽ EY No physician or other licensed health care provider order for this
item or service
Items billed before a signed and dated order has been received by
the supplier must be submitted with an EY modifier added to each
related HCPCS code.
✽ F1 Left hand, second digit
✽ F2 Left hand, third digit
✽ F3 Left hand, fourth digit
✽ F4 Left hand, fifth digit
✽ F5 Right hand, thumb
✽ F6 Right hand, second digit
✽ F7 Right hand, third digit
✽ F8 Right hand, fourth digit
✽ F9 Right hand, fifth digit
✽ FA Left hand, thumb
FB Item provided without cost to provider, supplier or practitioner, or
full credit received for replaced device (examples, but not limited
to, covered under warranty, replaced due to defect, free samples)
❂ FC Partial credit received for replaced device
✽ FP Service provided as part of family planning program
✽ FQ The service was furnished using audio-only communication
technology
✽ FR The supervising practitioner was present through two-way,
audio/video communication technology

✽ FS Split (or shared) evaluation and management visit

✽ FT Unrelated evaluation and management (e/m) visit during a
 postoperative period, or on the same day as a procedure or
another E/M visit. (report when an e/m visit is furnished within
the global period but is unrelated, or when one or more additional
E/M visits furnished on the same day are unrelated)
✽ FX X-ray taken using film
Coding Clinic: 2017, Q1, P6
✽ FY X-ray taken using computed radiography technology/cassette-
based imaging
✽ G0 Telehealth services for diagnosis, evaluation, or treatment, of
symptoms of an acute stroke
✽ G1 Most recent URR reading of less than 60
IOM: 100-04, 8, 50.9
✽ G2 Most recent URR reading of 60 to 64.9
IOM: 100-04, 8, 50.9
✽ G3 Most recent URR reading of 65 to 69.9
IOM: 100-04, 8, 50.9
✽ G4 Most recent URR reading of 70 to 74.9
IOM: 100-04, 8, 50.9
✽ G5 Most recent URR reading of 75 or greater
IOM: 100-04, 8, 50.9
✽ G6 ESRD patient for whom less than six dialysis sessions have been
provided in a month
IOM: 100-04, 8, 50.9
❂ G7 Pregnancy resulted from rape or incest or pregnancy certified by
physician as life threatening
IOM: 100-02, 15, 20.1; 100-03, 3, 170.3
✽ G8 Monitored anesthesia care (MAC) for deep complex,
complicated, or markedly invasive surgical procedure
✽ G9 Monitored anesthesia care for patient who has history of severe
cardiopulmonary condition
✽ GA Waiver of liability statement issued as required by payer policy,
individual case
An item/service is expected to be denied as not reasonable and
necessary and an ABN is on file. Modifier GA can be used on
either a specific or a miscellaneous HCPCS code. Modifiers GA
and GY should never be reported together on the same line for the
same HCPCS code.
✽ GB Claim being resubmitted for payment because it is no longer
covered under a global payment demonstration
❂ GC This service has been performed in part by a resident under the
direction of a teaching physician
IOM: 100-04, 12, 90.4, 100
❂ GE This service has been performed by a resident without the
presence of a teaching physician under the primary care exception
✽ GF Non-physician (e.g., nurse practitioner (NP), certified registered
nurse anesthetist (CRNA), certified registered nurse (CRN),
clinical nurse specialist (CNS), physician assistant (PA)) services
in a critical access hospital
✽ GG Performance and payment of a screening mammogram and
diagnostic mammogram on the same patient, same day
✽ GH Diagnostic mammogram converted from screening mammogram
on same day
✽ GJ “Opt out” physician or practitioner emergency or urgent service
✽ GK Reasonable and necessary item/service associated with a GA or
GZ modifier
An upgrade is defined as an item that goes beyond what is
medically necessary under Medicare’s coverage requirements. An
item can be considered an upgrade even if the physician has
signed an order for it. When suppliers know that an item will not
be paid in full because it does not meet the coverage criteria
stated in the LCD, the supplier can still obtain partial payment at
the time of initial determination if the claim is billed using one of
the upgrade modifiers (GK or GL).
(https://www.cms.gov/manuals/downloads/clm104c01.pdf)
✽ GL Medically unnecessary upgrade provided instead of non-upgraded
item, no charge, no Advance Beneficiary Notice (ABN)
✽ GM Multiple patients on one ambulance trip
✽ GN Services delivered under an outpatient speech language pathology
plan of care
✽ GO Services delivered under an outpatient occupational therapy plan
of care
✽ GP Services delivered under an outpatient physical therapy plan of
care
✽ GQ Via asynchronous telecommunications system
✽ GR This service was performed in whole or in part by a resident in a
Department of Veterans Affairs medical center or clinic,
supervised in accordance with VA policy
❂ GS Dosage of erythropoietin-stimulating agent has been reduced and
maintained in response to hematocrit or hemoglobin level
❂ GT Via interactive audio and video telecommunication systems
✽ GU Waiver of liability statement issued as required by payer policy,
routine notice
❂ GV Attending physician not employed or paid under arrangement by
the patient’s hospice provider
❂ GW Service not related to the hospice patient’s terminal condition
✽ GX Notice of liability issued, voluntary under payer policy
GX modifier must be submitted with non-covered charges only.
This modifier differentiates from the required uses in conjunction
with ABN.
(https://www.cms.gov/manuals/downloads/clm104c01.pdf)
GY Item or service statutorily excluded, does not meet the definition
of any Medicare benefit or, for non-Medicare insurers, is not a
contract benefit
Examples of “statutorily excluded” include: Infusion drug not
administered using a durable infusion pump, a wheelchair that is
for use for mobility outside the home or hearing aids. GA and GY
should never be coded together on the same line for the same
HCPCS code.
(https://www.cms.gov/manuals/downloads/clm104c01.pdf)
GZ Item or service expected to be denied as not reasonable or
necessary
Used when an ABN is not on file and can be used on either a
specific or a miscellaneous HCPCS code. It would never be
correct to place any combination of GY, GZ or GA modifiers on
the same claim line and will result in rejected or denied claim for
invalid coding.
(https://www.cms.gov/manuals/downloads/clm104c01.pdf)

H9 Court-ordered
HA Child/adolescent program
HB Adult program, nongeriatric
HC Adult program, geriatric
HD Pregnant/parenting women’s program
HE Mental health program
HF Substance abuse program
HG Opioid addiction treatment program
HH Integrated mental health/substance abuse program
HI Integrated mental health and intellectual disability/developmental
disabilities program
HJ Employee assistance program
HK Specialized mental health programs for high-risk populations
HL Intern
HM Less than bachelors degree level
HN Bachelors degree level
HO Masters degree level
HP Doctoral level
HQ Group setting
HR Family/couple with client present
HS Family/couple without client present
HT Multi-disciplinary team
HU Funded by child welfare agency
HV Funded by state addictions agency
HW Funded by state mental health agency
HX Funded by county/local agency
HY Funded by juvenile justice agency
HZ Funded by criminal justice agency
✽ J1 Competitive acquisition program nopay submission for a
prescription number

✽ J2 Competitive acquisition program, restocking of emergency drugs

after emergency administration
✽ J3 Competitive acquisition program (CAP), drug not available
through CAP as written, reimbursed under average sales price
methodology
✽ J4 DMEPOS item subject to DMEPOS competitive bidding program
that is furnished by a hospital upon discharge
✽ J5 Off-the-shelf orthotic subject to dmepos competitive bidding
program that is furnished as part of a physical therapist or
occupational therapist professional service
✽ JA Administered intravenously
This modifier is informational only (not a payment modifier) and
may be submitted with all injection codes. According to
Medicare, reporting this modifier is voluntary. (CMS Pub. 100-
04, chapter 8, section 60.2.3.1 and Pub. 100-04, chapter 17,
section 80.11)
✽ JB Administered subcutaneously
✽ JC Skin substitute used as a graft
✽ JD Skin substitute not used as a graft
✽ JE Administered via dialysate
✽ JG Drug or biological acquired with 340B drug pricing program
discount, reported for informational purposes
✽ JW Drug amount discarded/not administered to any patient
Use JW to identify unused drugs or biologicals from single use
vial/package that are appropriately discarded. Bill on separate line
for payment of discarded drug/biological.
IOM: 100-4, 17, 40
Coding Clinic: 2016, Q4, P4-7; 2010, Q3, P10
▶ JZ Zero drug amount discarded/not administered to any patient
✽ K0 Lower extremity prosthesis functional Level 0 - does not have the
ability or potential to ambulate or transfer safely with or without
assistance and a prosthesis does not enhance their quality of life
or mobility.
✽ K1 Lower extremity prosthesis functional Level 1 - has the ability or
potential to use a prosthesis for transfers or ambulation on level
surfaces at fixed cadence. Typical of the limited and unlimited
household ambulator.

✽ K2 Lower extremity prosthesis functional Level 2 - has the ability or

potential for ambulation with the ability to traverse low level
environmental barriers such as curbs, stairs or uneven surfaces.
Typical of the limited community ambulator.
✽ K3 Lower extremity prosthesis functional Level 3 - has the ability or
potential for ambulation with variable cadence. Typical of the
community ambulator who has the ability to traverse most
 environmental barriers and may have vocational, therapeutic, or
exercise activity that demands prosthetic utilization beyond
simple locomotion.
✽ K4 Lower extremity prosthesis functional Level 4 - has the ability or
potential for prosthetic ambulation that exceeds the basic
ambulation skills, exhibiting high impact, stress, or energy levels,
typical of the prosthetic demands of the child, active adult, or
athlete.
✽ KA Add on option/accessory for wheelchair
✽ KB Beneficiary requested upgrade for ABN, more than 4 modifiers
identified on claim
✽ KC Replacement of special power wheelchair interface
✽ KD Drug or biological infused through DME
✽ KE Bid under round one of the DMEPOS competitive bidding
program for use with non-competitive bid base equipment
✽ KF Item designated by FDA as Class III device
✽ KG DMEPOS item subject to DMEPOS competitive bidding program
number 1
✽ KH DMEPOS item, initial claim, purchase or first month rental
✽ KI DMEPOS item, second or third month rental
✽ KJ DMEPOS item, parenteral enteral nutrition (PEN) pump or
capped rental, months four to fifteen
✽ KK DMEPOS item subject to DMEPOS competitive bidding program
number 2
✽ KL DMEPOS item delivered via mail
✽ KM Replacement of facial prosthesis including new
impression/moulage
✽ KN Replacement of facial prosthesis using previous master model
✽ KO Single drug unit dose formulation
✽ KP First drug of a multiple drug unit dose formulation
✽ KQ Second or subsequent drug of a multiple drug unit dose
formulation
✽ KR Rental item, billing for partial month
❂ KS Glucose monitor supply for diabetic beneficiary not treated with
insulin
✽ KT Beneficiary resides in a competitive bidding area and travels
 outside that competitive bidding area and receives a competitive
bid item
✽ KU DMEPOS item subject to DMEPOS competitive bidding program
number 3
✽ KV DMEPOS item subject to DMEPOS competitive bidding program
that is furnished as part of a professional service
✽ KW DMEPOS item subject to DMEPOS competitive bidding program
number 4
✽ KX Requirements specified in the medical policy have been met
Used for physical, occupational, or speech-language therapy to
request an exception to therapy payment caps and indicate the
services are reasonable and necessary and that there is
documentation of medical necessity in the patient’s medical
record. (Pub 100-04 Attachment - Business Requirements Centers
for Medicare and Medicaid Services, Transmittal 2457, April 27,
2012)
Medicare requires modifier KX for implanted permanent cardiac
pacemakers, single chamber or duel chamber, for one of the
following CPT codes: 33206, 33207, 33208.
✽ KY DMEPOS item subject to DMEPOS competitive bidding program
number 5
✽ KZ New coverage not implemented by managed care
✽ LC Left circumflex coronary artery
✽ LD Left anterior descending coronary artery
✽ LL Lease/rental (use the LL modifier when DME equipment rental is
to be applied against the purchase price)
✽ LM Left main coronary artery

✽ LR Laboratory round trip

❂ LS FDA-monitored intraocular lens implant
✽ LT Left side (used to identify procedures performed on the left side
of the body)
Modifiers LT and RT identify procedures which can be performed
on paired organs. Used for procedures performed on one side
only. Should also be used when the procedures are similar but not
identical and are performed on paired body parts.
Coding Clinic: 2016, Q3, P5
▶ LU Fractionated payment of CAR-T therapy
✽ M2 Medicare secondary payer (MSP)
✽ MA Ordering professional is not required to consult a clinical decision
support mechanism due to service being rendered to a patient
with a suspected or confirmed emergency medical condition
✽ MB Ordering professional is not required to consult a clinical decision
support mechanism due to the significant hardship exception of
insufficient internet access
✽ MC Ordering professional is not required to consult a clinical decision
support mechanism due to the significant hardship exception of
electronic health record or clinical decision support mechanism
vendor issues
✽ MD Ordering professional is not required to consult a clinical decision
support mechanism due to the significant hardship exception of
extreme and uncontrollable circumstances
✽ ME The order for this service adheres to appropriate use criteria in the
clinical decision support mechanism consulted by the ordering
professional
✽ MF The order for this service does not adhere to the appropriate use
criteria in the clinical decision support mechanism consulted by
the ordering professional
✽ MG The order for this service does not have applicable appropriate
use criteria in the qualified clinical decision support mechanism
consulted by the ordering professional
✽ MH Unknown if ordering professional consulted a clinical decision
support mechanism for this service, related information was not
provided to the furnishing professional or provider

✽ MS Six month maintenance and servicing fee for reasonable and

necessary parts and labor which are not covered under any
manufacturer or supplier warranty
✽ NB Nebulizer system, any type, FDA-cleared for use with specific
drug
✽ NR New when rented (use the NR modifier when DME which was
new at the time of rental is subsequently purchased)
✽ NU New equipment
✽ P1 A normal healthy patient
✽ P2 A patient with mild systemic disease
✽ P3 A patient with severe systemic disease
✽ P4 A patient with severe systemic disease that is a constant threat to
life
✽ P5 A moribund patient who is not expected to survive without the
operation
✽ P6 A declared brain-dead patient whose organs are being removed
for donor purposes
PA Surgical or other invasive procedure on wrong body part
PB Surgical or other invasive procedure on wrong patient
PC Wrong surgery or other invasive procedure on patient
✽ PD Diagnostic or related non diagnostic item or service provided in a
wholly owned or operated entity to a patient who is admitted as
an inpatient within 3 days
✽ PI Positron emission tomography (PET) or PET/computed
tomography (CT) to inform the initial treatment strategy of
tumors that are biopsy proven or strongly suspected of being
cancerous based on other diagnostic testing
✽ PL Progressive addition lenses
✽ PM Post mortem
✽ PN Non-excepted service provided at an off-campus, outpatient,
provider-based department of a hospital
✽ PO Expected services provided at off-campus, outpatient, provider-
based department of a hospital
✽ PS Positron emission tomography (PET) or PET/computed
tomography (CT) to inform the subsequent treatment strategy of
cancerous tumors when the beneficiary’s treating physician
determines that the PET study is needed to inform subsequent
antitumor strategy

✽ PT Colorectal cancer screening test; converted to diagnostic text or

other procedure
Assign this modifier with the appropriate CPT procedure code for
colonoscopy, flexible sigmoidoscopy, or barium enema when the
service is initiated as a colorectal cancer screening service but
then becomes a diagnostic service. MLN Matters article MM7012
(PDF, 75 KB) Reference Medicare Transmittal 3232 April 3,
2015.
Coding Clinic: 2011, Q1, P10
❂ Q0 Investigational clinical service provided in a clinical research
 study that is in an approved clinical research study
❂ Q1 Routine clinical service provided in a clinical research study that
is in an approved clinical research study
✽ Q2 Demonstration procedure/service
✽ Q3 Live kidney donor surgery and related services
✽ Q4 Service for ordering/referring physician qualifies as a service
exemption
❂ Q5 Service furnished under a reciprocal billing arrangement by a
substitute physician or by a substitute physical therapist
furnishing outpatient physical therapy services in a health
professional shortage area, a medically underserved area, or a
rural area
IOM: 100-04, 1, 30.2.10
❂ Q6 Service furnished under a fee-for-time compensation arrangement
by a substitute physician or by a substitute physical therapist
furnishing outpatient physical therapy services in a health
professional shortage area, a medically underserved area, or a
rural area
IOM: 100-04, 1, 30.2.11
✽ Q7 One Class A finding
✽ Q8 Two Class B findings
✽ Q9 One Class B and two Class C findings
✽ QA Prescribed amounts of stationary oxygen for daytime use while at
rest and nighttime use differ and the average of the two amounts
is less than 1 liter per minute (lpm)

✽ QB Prescribed amounts of stationary oxygen for daytime use while at

rest and nighttime use differ and the average of the two amounts
exceeds 4 liters per minute (lpm) and portable oxygen is
prescribed
✽ QC Single channel monitoring
✽ QD Recording and storage in solid state memory by a digital recorder
✽ QE Prescribed amount of stationary oxygen while at rest is less than 1
liter per minute (LPM)
✽ QF Prescribed amount of stationary oxygen while at rest exceeds 4
liters per minute (LPM) and portable oxygen is prescribed
✽ QG Prescribed amount of stationary oxygen while at rest is greater
 than 4 liters per minute (LPM)
✽ QH Oxygen conserving device is being used with an oxygen delivery
system
❂ QJ Services/items provided to a prisoner or patient in state or local
custody, however, the state or local government, as applicable,
meets the requirements in 42 CFR 411.4 (B)
❂ QK Medical direction of two, three, or four concurrent anesthesia
procedures involving qualified individuals
IOM: 100-04, 12, 50K, 90
✽ QL Patient pronounced dead after ambulance called
✽ QM Ambulance service provided under arrangement by a provider of
services
✽ QN Ambulance service furnished directly by a provider of services
❂ QP Documentation is on file showing that the laboratory test(s) was
ordered individually or ordered as a CPT-recognized panel other
than automated profile codes 80002-80019, G0058, G0059, and
G0060
✽ QQ Ordering professional consulted a qualified clinical decision
support mechanism for this service and the related data was
provided to the furnishing professional
✽ QR Prescribed amounts of stationary oxygen for daytime use while at
rest and nighttime use differ and the average of the two amounts
is greater than 4 liters per minute (lpm)

❂ QS Monitored anesthesia care service

IOM: 100-04, 12, 30.6, 501
✽ QT Recording and storage on tape by an analog tape recorder
✽ QW CLIA-waived test
✽ QX CRNA service: with medical direction by a physician
❂ QY Medical direction of one certified registered nurse anesthetist
(CRNA) by an anesthesiologist
IOM: 100-04, 12, 50K, 90
✽ QZ CRNA service: without medical direction by a physician
✽ RA Replacement of a DME, orthotic or prosthetic item
Contractors will deny claims for replacement parts when
furnished in conjunction with the repair of a capped rental item
and billed with modifier RB, including claims for parts submitted
 using code E1399, that are billed during the capped rental period
(i.e., the last day of the 13th month of continuous use or before).
Repair includes all maintenance, servicing, and repair of capped
rental DME because it is included in the allowed rental payment
amounts. (Pub 100-20 One-Time Notification Centers for
Medicare &amp; Medicaid Services, Transmittal: 901, May 13,
2011)
✽ RB Replacement of a part of a DME, orthotic or prosthetic item
furnished as part of a repair
✽ RC Right coronary artery
✽ RD Drug provided to beneficiary, but not administered “incident-to”
✽ RE Furnished in full compliance with FDA-mandated risk evaluation
and mitigation strategy (REMS)
✽ RI Ramus intermedius coronary artery
✽ RR Rental (use the ‘RR’ modifier when DME is to be rented)
✽ RT Right side (used to identify procedures performed on the right
side of the body)
Modifiers LT and RT identify procedures which can be performed
on paired organs. Used for procedures performed on one side
only. Should also be used when the procedures are similar but not
identical and are performed on paired body parts.
Coding Clinic: 2016, Q3, P5
SA Nurse practitioner rendering service in collaboration with a
physician
SB Nurse midwife
✽ SC Medically necessary service or supply
SD Services provided by registered nurse with specialized, highly
technical home infusion training
SE State and/or federally funded programs/services
✽ SF Second opinion ordered by a professional review organization
(PRO) per Section 9401, P.L. 99-272 (100% reimbursement – no
Medicare deductible or coinsurance)
✽ SG Ambulatory surgical center (ASC) facility service
Only valid for surgical codes. After 1/1/08 not required for ASC
facility charges.
SH Second concurrently administered infusion therapy
SJ Third or more concurrently administered infusion therapy
SK Member of high risk population (use only with codes for
immunization)
SL State supplied vaccine
SM Second surgical opinion
SN Third surgical opinion
SQ Item ordered by home health
SS Home infusion services provided in the infusion suite of the IV
therapy provider
ST Related to trauma or injury
SU Procedure performed in physician’s office (to denote use of
facility and equipment)
SV Pharmaceuticals delivered to patient’s home but not utilized
✽ SW Services provided by a certified diabetic educator
SY Persons who are in close contact with member of high-risk
population (use only with codes for immunization)
✽ T1 Left foot, second digit
✽ T2 Left foot, third digit
✽ T3 Left foot, fourth digit
✽ T4 Left foot, fifth digit

✽ T5 Right foot, great toe

✽ T6 Right foot, second digit
✽ T7 Right foot, third digit
✽ T8 Right foot, fourth digit
✽ T9 Right foot, fifth digit
✽ TA Left foot, great toe
✽ TB Drug or biological acquired with 340B drug pricing program
discount, reported for informational purposes for select entities
✽ TC Technical component; under certain circumstances, a charge may
be made for the technical component alone; under those
circumstances the technical component charge is identified by
adding modifier TC to the usual procedure number; technical
component charges are institutional charges and not billed
separately by physicians; however, portable x-ray suppliers only
bill for technical component and should utilize modifier TC; the
charge data from portable x-ray suppliers will then be used to
 build customary and prevailing profiles.
TD RN
TE LPN/LVN
TF Intermediate level of care
TG Complex/high tech level of care
TH Obstetrical treatment/services, prenatal or postpartum
TJ Program group, child and/or adolescent
TK Extra patient or passenger, nonambulance
TL Early intervention/individualized family service plan (IFSP)
TM Individualized education program (IEP)
TN Rural/outside providers’ customary service area
TP Medical transport, unloaded vehicle
TQ Basic life support transport by a volunteer ambulance provider
TR School-based individual education program (IEP) services
provided outside the public school district responsible for the
student

✽ TS Follow-up service
TT Individualized service provided to more than one patient in same
setting
TU Special payment rate, overtime
TV Special payment rates, holidays/weekends
TW Back-up equipment
U1 Medicaid Level of Care 1, as defined by each State
U2 Medicaid Level of Care 2, as defined by each State
U3 Medicaid Level of Care 3, as defined by each State
U4 Medicaid Level of Care 4, as defined by each State
U5 Medicaid Level of Care 5, as defined by each State
U6 Medicaid Level of Care 6, as defined by each State
U7 Medicaid Level of Care 7, as defined by each State
U8 Medicaid Level of Care 8, as defined by each State
U9 Medicaid Level of Care 9, as defined by each State
UA Medicaid Level of Care 10, as defined by each State
UB Medicaid Level of Care 11, as defined by each State
UC Medicaid Level of Care 12, as defined by each State
UD Medicaid Level of Care 13, as defined by each State
✽ UE Used durable medical equipment
UF Services provided in the morning
UG Services provided in the afternoon
UH Services provided in the evening
✽ UJ Services provided at night
UK Services provided on behalf of the client to someone other than
the client (collateral relationship)
✽ UN Two patients served
✽ UP Three patients served
✽ UQ Four patients served
✽ UR Five patients served
✽ US Six or more patients served
✽ V1 Demonstration Modifier 1
✽ V2 Demonstration Modifier 2

✽ V3 Demonstration Modifier 3
✽ V4 Demonstration modifier 4
✽ V5 Vascular catheter (alone or with any other vascular access)
✽ V6 Arteriovenous graft (or other vascular access not including a
vascular catheter)
✽ V7 Arteriovenous fistula only (in use with two needles)
✽ VM Medicare diabetes prevention program (MDPP) virtual make-up
session
✽ VP Aphakic patient
✽ X1 Continuous/broad services: for reporting services by clinicians,
who provide the principal care for a patient, with no planned
endpoint of the relationship; services in this category represent
comprehensive care, dealing with the entire scope of patient
problems, either directly or in a care coordination role; reporting
clinician service examples include, but are not limited to: primary
care, and clinicians providing comprehensive care to patients in
addition to specialty care
✽ X2 Continuous/focused services: for reporting services by clinicians
whose expertise is needed for the ongoing management of a
chronic disease or a condition that needs to be managed and
followed with no planned endpoint to the relationship; reporting
clinician service examples include but are not limited to: a
rheumatologist taking care of the patient’s rheumatoid arthritis
longitudinally but not providing general primary care services
✽ X3 Episodic/broad services: for reporting services by clinicians who
have broad responsibility for the comprehensive needs of the
patient that is limited to a defined period and circumstance such
as a hospitalization; reporting clinician service examples include
but are not limited to the hospitalist’s services rendered providing
comprehensive and general care to a patient while admitted to the
hospital
✽ X4 Episodic/focused services: for reporting services by clinicians
who provide focused care on particular types of treatment limited
to a defined period and circumstance; the patient has a problem,
acute or chronic, that will be treated with surgery, radiation, or
some other type of generally time-limited intervention; reporting
clinician service examples include but are not limited to, the
orthopedic surgeon performing a knee replacement and seeing the
patient through the postoperative period
✽ X5 Diagnostic services requested by another clinician: for reporting
services by a clinician who furnishes care to the patient only as
requested by another clinician or subsequent and related services
requested by another clinician; this modifier is reported for
patient relationships that may not be adequately captured by the
above alternative categories; reporting clinician service examples
include but are not limited to, the radiologist’s interpretation of an
imaging study requested by another clinician
✽ XE Separate encounter, a service that is distinct because it occurred
during a separate encounter
✽ XP Separate practitioner, a service that is distinct because it was
performed by a different practitioner
✽ XS Separate structure, a service that is distinct because it was
performed on a separate organ/structure
✽ XU Unusual non-overlapping service, the use of a service that is
distinct because it does not overlap usual components of the main
service
Ambulance Modifiers
Modifiers that are used on claims for ambulance services are created by
combining two alpha characters. Each alpha character, with the exception of X,
represents an origin (source) code or a destination code. The pair of alpha codes
creates one modifier. The first position alpha-code = origin; the second position
alpha-code = destination. On form CMS-1491, used to report ambulance
services, Item 12 should contain the origin code and Item 13 should contain the
destination code. Origin and destination codes and their descriptions are as
follows:

D Diagnostic or therapeutic site other than P or H when these are used as

origin codes
E Residential, domiciliary, custodial facility (other than an 1819 facility)
G Hospital-based ESRD facility
H Hospital
I Site of transfer (e.g., airport or helicopter pad) between modes of
ambulance transport
J Freestanding ESRD facility
N Skilled nursing facility
P Physician’s office
R Residence
S Scene of accident or acute event
X Intermediate stop at physician’s office on way to hospital (destination code
only)

◀ New Revised ✔ Reinstated deleted Deleted Not covered or valid by Medicare ❂ Special

coverage instructions ✽ Carrier discretion Bill Part B MAC Bill DME MAC MIPS

Quantity Physician Quantity Hospital ♀ Female only ♂ Male only Age

DMEPOS A2-Z3 ASC Payment Indicator A-Y ASC Status Indicator Coding Clinic
TRANSPORT SERVICES INCLUDING AMBULANCE
(A0000-A0999)
A0021 Ambulance service, outside state per mile, transport (Medicaid only)
E1

Cross Reference A0030

A0080 Non-emergency transportation, per mile - vehicle provided by
volunteer (individual or organization), with no vested interest
E1
A0090 Non-emergency transportation, per mile - vehicle provided by
individual (family member, self, neighbor) with vested interest
E1
A0100 Non-emergency transportation; taxi E1

A0110 Non-emergency transportation and bus, intra- or interstate carrier

E1

A0120 Non-emergency transportation: mini-bus, mountain area transports,

or other transportation systems E1

A0130 Non-emergency transportation: wheelchair van E1

A0140 Non-emergency transportation and air travel (private or

commercial), intra- or interstate E1

A0160 Non-emergency transportation: per mile - caseworker or social

worker E1

A0170 Transportation: ancillary: parking fees, tolls, other E1

A0180 Non-emergency transportation: ancillary: lodging - recipient

E1
A0190 Non-emergency transportation: ancillary: meals - recipient
E1
A0200 Non-emergency transportation: ancillary: lodging - escort
E1
A0210 Non-emergency transportation: ancillary: meals - escort
E1
A0225 Ambulance service, neonatal transport, base rate, emergency
transport, one way E1

A0380 BLS mileage (per mile) E1

Cross Reference A0425

A0382 BLS routine disposable supplies E1

A0384 BLS specialized service disposable supplies; defibrillation (used by

 ALS ambulances and BLS ambulances in jurisdictions where
defibrillation is permitted in BLS ambulances) E1

A0390 ALS mileage (per mile) E1

Cross Reference A0425

A0392 ALS specialized service disposable supplies; defibrillation (to be
used only in jurisdictions where defibrillation cannot be performed
in BLS ambulances) E1

A0394 ALS specialized service disposable supplies; IV drug therapy

E1
A0396 ALS specialized service disposable supplies; esophageal intubation
E1

A0398 ALS routine disposable supplies E1

A0420 Ambulance waiting time (ALS or BLS), one half (½) hour
increments E1

Waiting Time Table

UNITS TIME
1 ½ to 1 hr.
2 1 to 1½ hrs.
3 1½ to 2 hrs.
4 2 to 2½ hrs.
5 2½ to 3 hrs.
6 3 to 3½ hrs.
7 3½ to 4 hrs.
8 4 to 4½ hrs.
9 4½ to 5 hrs.
10 5 to 5½ hrs.

A0422 Ambulance (ALS or BLS) oxygen and oxygen supplies, life

sustaining situation E1

A0424 Extra ambulance attendant, ground (ALS or BLS) or air (fixed or

rotary winged); (requires medical review) E1

✽ A0425 Ground mileage, per statute mile A

✽ A0426 Ambulance service, advanced life support, non-emergency

transport, Level 1 (ALS 1) A

✽ A0427 Ambulance service, advanced life support, emergency transport,

Level 1 (ALS 1-Emergency) A

✽ A0428 Ambulance service, basic life support, non-emergency transport

(BLS) A
 ✽ A0429 Ambulance service, basic life support, emergency transport (BLS-
Emergency) A

✽ A0430 Ambulance service, conventional air services, transport, one way

(fixed wing) A

✽ A0431 Ambulance service, conventional air services, transport, one way

(rotary wing) A

✽ A0432 Paramedic intercept (PI), rural area, transport furnished by a

volunteer ambulance company, which is prohibited by state law
from billing third party payers A

✽ A0433 Advanced life support, Level 2 (ALS2) A

✽ A0434 Specialty care transport (SCT) A

✽ A0435 Fixed wing air mileage, per statute mile A

✽ A0436 Rotary wing air mileage, per statute mile A

A0888 Noncovered ambulance mileage, per mile (e.g., for miles traveled
beyond closest appropriate facility) E1

MCM: 2125
A0998 Ambulance response and treatment, no transport E1

IOM: 100-02, 10, 20

❂ A0999 Unlisted ambulance service A

IOM: 100-02, 10, 20

MEDICAL AND SURGICAL SUPPLIES (A2001-A8004)

Wound Supplies
A2001 Innovamatrix ac, per square centimeter N1

A2002 Mirragen advanced wound matrix, per square centimeter N1

A2003 Bio-connekt wound matrix, per square centimeter N1

A2004 Xcellistem, 1 mg N1

A2005 Microlyte matrix, per square centimeter N1

A2006 Novosorb synpath dermal matrix, per square centimeter N1

A2007 Restrata, per square centimeter N1

A2008 Theragenesis, per square centimeter N1

A2009 Symphony, per square centimeter N1

A2010 Apis, per square centimeter N1

▶ A2014 Omeza collagen matrix, per 100 mg N1

 ▶ A2015 Phoenix wound matrix, per square centimeter N1

▶ A2016 Permeaderm B, per square centimeter N1

▶ A2017 Permeaderm glove, each N1

▶ A2018 Permeaderm C, per square centimeter N1

Injection and Infusion

✽ A4206 Syringe with needle, sterile 1 cc or less, each N

✽ A4207 Syringe with needle, sterile 2 cc, each N

✽ A4208 Syringe with needle, sterile 3 cc, each N

✽ A4209 Syringe with needle, sterile 5 cc or greater, each N

A4210 Needle-free injection device, each E1

IOM: 100-03, 4, 280.1

❂ A4211 Supplies for self-administered injections N

IOM: 100-02, 15, 50

✽ A4212 Non-coring needle or stylet with or without catheter N

✽ A4213 Syringe, sterile, 20 cc or greater, each N

✽ A4215 Needle, sterile, any size, each N

❂ A4216 Sterile water, saline and/or dextrose diluent/flush, 10 ml N

Other: Sodium Chloride, Bacteriostatic, Syrex

IOM: 100-02, 15, 50
❂ A4217 Sterile water/saline, 500 ml N

Other: Sodium Chloride

IOM: 100-02, 15, 50
❂ A4218 Sterile saline or water, metered dose dispenser, 10 ml N

Other: Sodium Chloride

❂ A4220 Refill kit for implantable infusion pump N

Do not report with 95990 or 95991 since Medicare payment for

these codes includes the refill kit.
IOM: 100-03, 4, 280.1
✽ A4221 Supplies for maintenance of noninsulin drug infusion catheter, per
week (list drugs separately) N

Includes dressings for catheter site and flush solutions not directly
related to drug infusion.
 ✽ A4222 Infusion supplies for external drug infusion pump, per cassette or
bag (list drug separately) N

Includes cassette or bag, diluting solutions, tubing and/or

administration supplies, port cap changes, compounding charges,
and preparation charges.
✽ A4223 Infusion supplies not used with external infusion pump, per cassette
or bag (list drugs separately) N

IOM: 100-03, 4, 280.1

Figure 1 Insulin pump.

✽ A4224 Supplies for maintenance of insulin infusion catheter, per week

N

❂ A4225 Supplies for external insulin infusion pump, syringe type cartridge,
sterile, each N

IOM: 100-03, 1, 50.3

✽ A4226 Supplies for maintenance of insulin infusion pump with dosage rate
adjustment using therapeutic continuous glucose sensing, per week
N
❂ A4230 Infusion set for external insulin pump, non-needle cannula type
N
Requires prior authorization and copy of invoice.
IOM: 100-03, 4, 280.1
❂ A4231 Infusion set for external insulin pump, needle type N

Requires prior authorization and copy of invoice.

IOM: 100-03, 4, 280.1
A4232 Syringe with needle for external insulin pump, sterile, 3 cc
E1
Reports insulin reservoir for use with external insulin infusion
pump (E0784); may be glass or plastic; includes needle for drawing
 up insulin. Does not include insulin for use in reservoir.
IOM: 100-03, 4, 280.1

Replacement Batteries
✽ A4233 Replacement battery, alkaline (other than J cell), for use with
medically necessary home blood glucose monitor owned by patient,
each E1

✽ A4234 Replacement battery, alkaline, J cell, for use with medically

necessary home blood glucose monitor owned by patient, each
E1
✽ A4235 Replacement battery, lithium, for use with medically necessary
home blood glucose monitor owned by patient, each E1

✽ A4236 Replacement battery, silver oxide, for use with medically necessary
home blood glucose monitor owned by patient, each E1

Miscellaneous Supplies
▶ A4238 Supply allowance for adjunctive, non-implanted continuous glucose
monitor (cgm), includes all supplies and accessories, 1 month
supply = 1 unit of service
▶ A4239 Supply allowance for non-adjunctive, non-implanted continuous
glucose monitor (cgm), includes all supplies and accessories, 1
month supply = 1 unit of service Y

✽ A4244 Alcohol or peroxide, per pint N

✽ A4245 Alcohol wipes, per box N

✽ A4246 Betadine or Phisohex solution, per pint N

✽ A4247 Betadine or iodine swabs/wipes, per box N

✽ A4248 Chlorhexidine containing antiseptic, 1 ml N

A4250 Urine test or reagent strips or tablets (100 tablets or strips)

E1
IOM: 100-02, 15, 110
A4252 Blood ketone test or reagent strip, each E1

Medicare Statute 1861(n)

❂ A4253 Blood glucose test or reagent strips for home blood glucose monitor,
per 50 strips N

Test strips (1 unit = 50 strips); noninsulin treated (every 3 months)

100 test strips (1×/day testing), 100 lancets (1×/day testing);
modifier KS
 IOM: 100-03, 1, 40.2
❂ A4255 Platforms for home blood glucose monitor, 50 per box
N
IOM: 100-03, 1, 40.2
❂ A4256 Normal, low and high calibrator solution/chips N

IOM: 100-03, 1, 40.2

✽ A4257 Replacement lens shield cartridge for use with laser skin piercing
device, each E1

❂ A4258 Spring-powered device for lancet, each N

IOM: 100-03, 1, 40.2

❂ A4259 Lancets, per box of 100 N

IOM: 100-03, 1, 40.2

A4261 Cervical cap for contraceptive use ♀ E1

Medicare Statute 1862A1

❂ A4262 Temporary, absorbable lacrimal duct implant, each N

IOM: 100-04, 12, 20.3, 30.4

❂ A4263 Permanent, long term, non-dissolvable lacrimal duct implant, each
N

Bundled with insertion if performed in physician office.

IOM: 100-04, 12, 30.4
A4264 Permanent implantable contraceptive intratubal occlusion device(s)
and delivery system ♀ E1

Reports the Essure device.

❂ A4265 Paraffin, per pound N

IOM: 100-03, 4, 280.1

A4266 Diaphragm for contraceptive use ♀ E1

A4267 Contraceptive supply, condom, male, each ♂ E1

A4268 Contraceptive supply, condom, female, each ♀ E1

A4269 Contraceptive supply, spermicide (e.g., foam, gel), each

E1
✽ A4270 Disposable endoscope sheath, each N

✽ A4280 Adhesive skin support attachment for use with external breast
prosthesis, each ♀ N

✽ A4281 Tubing for breast pump, replacement ♀ E1

✽ A4282 Adapter for breast pump, replacement ♀ E1

 ✽ A4283 Cap for breast pump bottle, replacement ♀ E1

✽ A4284 Breast shield and splash protector for use with breast pump,
replacement ♀ E1

✽ A4285 Polycarbonate bottle for use with breast pump, replacement ♀ E1

✽ A4286 Locking ring for breast pump, replacement ♀ E1

✽ A4290 Sacral nerve stimulation test lead, each N

Service not separately priced by Part B (e.g., services not covered,

bundled, used by Part A only)

Implantable Catheters
❂ A4300 Implantable access catheter, (e.g., venous, arterial, epidural
subarachnoid, or peritoneal, etc.) external access N

IOM: 100-02, 15, 120

✽ A4301 Implantable access total; catheter, port/reservoir (e.g., venous,
arterial, epidural, subarachnoid, peritoneal, etc.) N

Disposable Drug Delivery System

✽ A4305 Disposable drug delivery system, flow rate of 50 ml or greater per
hour N

✽ A4306 Disposable drug delivery system, flow rate of less than 50 ml per
hour N

Incontinence Appliances and Care Supplies

❂ A4310 Insertion tray without drainage bag and without catheter
(accessories only) N

IOM: 100-02, 15, 120

❂ A4311 Insertion tray without drainage bag with indwelling catheter, Foley
type, two-way latex with coating (Teflon, silicone, silicone
elastomer, or hydrophilic, etc.) N

IOM: 100-02, 15, 120

❂ A4312 Insertion tray without drainage bag with indwelling catheter, Foley
type, two-way, all silicone N

Must meet criteria for indwelling catheter and medical record must
justify need for:
• Recurrent encrustation
 • Inability to pass a straight catheter
• Sensitivity to latex
Must be medically necessary.
IOM: 100-02, 15, 120
❂ A4313 Insertion tray without drainage bag with indwelling catheter, Foley
type, three-way, for continuous irrigation N

Must meet criteria for indwelling catheter and medical record must
justify need for:
• Recurrent encrustation
• Inability to pass a straight catheter
• Sensitivity to latex
Must be medically necessary.
IOM: 100-02, 15, 120

Figure 2 Foley catheter.

❂ A4314 Insertion tray with drainage bag with indwelling catheter, Foley
type, two-way latex with coating (Teflon, silicone, silicone
elastomer or hydrophilic, etc.) N

IOM: 100-02, 15, 120

❂ A4315 Insertion tray with drainage bag with indwelling catheter, Foley
type, two-way, all silicone N

IOM: 100-02, 15, 120

❂ A4316 Insertion tray with drainage bag with indwelling catheter, Foley
type, three-way, for continuous irrigation N

IOM: 100-02, 15, 120

❂ A4320 Irrigation tray with bulb or piston syringe, any purpose
N
IOM: 100-02, 15, 120
❂ A4321 Therapeutic agent for urinary catheter irrigation N

IOM: 100-02, 15, 120

❂ A4322 Irrigation syringe, bulb, or piston, each N

IOM: 100-02, 15, 120

❂ A4326 Male external catheter with integral collection chamber, any type,
each ♂ N

IOM: 100-02, 15, 120

❂ A4327 Female external urinary collection device; meatal cup, each
♀ N

IOM: 100-02, 15, 120

❂ A4328 Female external urinary collection device; pouch, each ♀
N
IOM: 100-02, 15, 120
❂ A4330 Perianal fecal collection pouch with adhesive, each N

IOM: 100-02, 15, 120

❂ A4331 Extension drainage tubing, any type, any length, with
connector/adaptor, for use with urinary leg bag or urostomy pouch,
each N

IOM: 100-02, 15, 120

❂ A4332 Lubricant, individual sterile packet, each N

IOM: 100-02, 15, 120

❂ A4333 Urinary catheter anchoring device, adhesive skin attachment, each
N

IOM: 100-02, 15, 120

❂ A4334 Urinary catheter anchoring device, leg strap, each N

IOM: 100-02, 15, 120

❂ A4335 Incontinence supply; miscellaneous N
 IOM: 100-02, 15, 120
❂ A4336 Incontinence supply, urethral insert, any type, each N

IOM: 100-02, 15, 120

❂ A4337 Incontinence supply, rectal insert, any type, each N

IOM: 100-02, 15, 120

❂ A4338 Indwelling catheter; Foley type, two-way latex with coating (Teflon,
silicone, silicone elastomer, or hydrophilic, etc.), each
N
IOM: 100-02, 15, 120
❂ A4340 Indwelling catheter; specialty type (e.g., coude, mushroom, wing,
etc.), each N

Must meet criteria for indwelling catheter and medical record must
justify need for:
• Recurrent encrustation
• Inability to pass a straight catheter
• Sensitivity to latex
Must be medically necessary.
IOM: 100-02, 15, 120
❂ A4344 Indwelling catheter, Foley type, two-way, all silicone, each
N

Must meet criteria for indwelling catheter and medical record must
justify need for:
• Recurrent encrustation
• Inability to pass a straight catheter
• Sensitivity to latex
Must be medically necessary.
IOM: 100-02, 15, 120
❂ A4346 Indwelling catheter; Foley type, three way for continuous irrigation,
each N

IOM: 100-02, 15, 120

❂ A4349 Male external catheter, with or without adhesive, disposable, each
♂ N

IOM: 100-02, 15, 120

❂ A4351 Intermittent urinary catheter; straight tip, with or without coating
(Teflon, silicone, silicone elastomer, or hydrophilic, etc.), each
N

IOM: 100-02, 15, 120

 ❂ A4352 Intermittent urinary catheter; coude (curved) tip, with or without
coating (Teflon, silicone, silicone elastomeric, or hydrophilic, etc.),
each N

IOM: 100-02, 15, 120

❂ A4353 Intermittent urinary catheter, with insertion supplies N

IOM: 100-02, 15, 120

❂ A4354 Insertion tray with drainage bag but without catheter
N
IOM: 100-02, 15, 120
❂ A4355 Irrigation tubing set for continuous bladder irrigation through a
three-way indwelling Foley catheter, each N

IOM: 100-02, 15, 120

External Urinary Supplies

❂ A4356 External urethral clamp or compression device (not to be used for
catheter clamp), each N

IOM: 100-02, 15, 120

❂ A4357 Bedside drainage bag, day or night, with or without anti-reflux
device, with or without tube, each N

IOM: 100-02, 15, 120

Figure 3 Ostomy pouch.

❂ A4358 Urinary drainage bag, leg or abdomen, vinyl, with or without tube,
with straps, each N

IOM: 100-02, 15, 120

❂ A4360 Disposable external urethral clamp or compression device, with pad
and/or pouch, each N
Ostomy Supplies
❂ A4361 Ostomy faceplate, each N

IOM: 100-02, 15, 120

❂ A4362 Skin barrier; solid, 4 × 4 or equivalent; each N

IOM: 100-02, 15, 120

❂ A4363 Ostomy clamp, any type, replacement only, each E1

❂ A4364 Adhesive, liquid or equal, any type, per oz N

Fee schedule category: Ostomy, tracheostomy, and urologicals

items.
IOM: 100-02, 15, 120
✽ A4366 Ostomy vent, any type, each N

❂ A4367 Ostomy belt, each N

IOM: 100-02, 15, 120

✽ A4368 Ostomy filter, any type, each N

❂ A4369 Ostomy skin barrier, liquid (spray, brush, etc.), per oz N

IOM: 100-02, 15, 120

❂ A4371 Ostomy skin barrier, powder, per oz N

IOM: 100-02, 15, 120

❂ A4372 Ostomy skin barrier, solid 4 × 4 or equivalent, standard wear, with
built-in convexity, each N

IOM: 100-02, 15, 120

❂ A4373 Ostomy skin barrier, with flange (solid, flexible, or accordion), with
built-in convexity, any size, each N

IOM: 100-02, 15, 120

❂ A4375 Ostomy pouch, drainable, with faceplate attached, plastic, each
N

IOM: 100-02, 15, 120

❂ A4376 Ostomy pouch, drainable, with faceplate attached, rubber, each
N

IOM: 100-02, 15, 120

❂ A4377 Ostomy pouch, drainable, for use on faceplate, plastic, each
N

IOM: 100-02, 15, 120

❂ A4378 Ostomy pouch, drainable, for use on faceplate, rubber, each
N
 IOM: 100-02, 15, 120
❂ A4379 Ostomy pouch, urinary, with faceplate attached, plastic, each
N

IOM: 100-02, 15, 120

❂ A4380 Ostomy pouch, urinary, with faceplate attached, rubber, each
N

IOM: 100-02, 15, 120

❂ A4381 Ostomy pouch, urinary, for use on faceplate, plastic, each
N

IOM: 100-02, 15, 120

❂ A4382 Ostomy pouch, urinary, for use on faceplate, heavy plastic, each
N

IOM: 100-02, 15, 120

❂ A4383 Ostomy pouch, urinary, for use on faceplate, rubber, each
N
IOM: 100-02, 15, 120
❂ A4384 Ostomy faceplate equivalent, silicone ring, each N

IOM: 100-02, 15, 120

❂ A4385 Ostomy skin barrier, solid 4 × 4 or equivalent, extended wear,
without built-in convexity, each N

IOM: 100-02, 15, 120

❂ A4387 Ostomy pouch closed, with barrier attached, with built-in convexity
(1 piece), each N

IOM: 100-02, 15, 120

❂ A4388 Ostomy pouch, drainable, with extended wear barrier attached (1
piece), each N

IOM: 100-02, 15, 120

❂ A4389 Ostomy pouch, drainable, with barrier attached, with built-in
convexity (1 piece), each N

IOM: 100-02, 15, 120

❂ A4390 Ostomy pouch, drainable, with extended wear barrier attached, with
built-in convexity (1 piece), each N

IOM: 100-02, 15, 120

❂ A4391 Ostomy pouch, urinary, with extended wear barrier attached (1
piece), each N

IOM: 100-02, 15, 120

❂ A4392 Ostomy pouch, urinary, with standard wear barrier attached, with
built-in convexity (1 piece), each N

IOM: 100-02, 15, 120

❂ A4393 Ostomy pouch, urinary, with extended wear barrier attached, with
built-in convexity (1 piece), each N

IOM: 100-02, 15, 120

❂ A4394 Ostomy deodorant, with or without lubricant, for use in ostomy
pouch, per fluid ounce N

IOM: 100-02, 15, 20

❂ A4395 Ostomy deodorant for use in ostomy pouch, solid, per tablet
N
IOM: 100-02, 15, 20
❂ A4396 Ostomy belt with peristomal hernia support N

IOM: 100-02, 15, 120

❂ A4398 Ostomy irrigation supply; bag, each N

IOM: 100-02, 15, 120

❂ A4399 Ostomy irrigation supply; cone/catheter, with or without brush
N

IOM: 100-02, 15, 120

❂ A4400 Ostomy irrigation set N

IOM: 100-02, 15, 120

❂ A4402 Lubricant, per ounce N

IOM: 100-02, 15, 120

❂ A4404 Ostomy ring, each N

IOM: 100-02, 15, 120

❂ A4405 Ostomy skin barrier, non-pectin based, paste, per ounce N

IOM: 100-02, 15, 120

❂ A4406 Ostomy skin barrier, pectin-based, paste, per ounce N

IOM: 100-02, 15, 120

❂ A4407 Ostomy skin barrier, with flange (solid, flexible, or accordion),
extended wear, with built-in convexity, 4 × 4 inches or smaller, each
N

IOM: 100-02, 15, 120

❂ A4408 Ostomy skin barrier, with flange (solid, flexible, or accordion),
extended wear, with built-in convexity, larger than 4 × 4 inches,
each N

IOM: 100-02, 15, 120

❂ A4409 Ostomy skin barrier, with flange (solid, flexible, or accordion),
extended wear, without built-in convexity, 4 × 4 inches or smaller,
each N

IOM: 100-02, 15, 120

❂ A4410 Ostomy skin barrier, with flange (solid, flexible, or accordion),
extended wear, without built-in convexity, larger than 4 × 4 inches,
each N

IOM: 100-02, 15, 120

❂ A4411 Ostomy skin barrier, solid 4 × 4 or equivalent, extended wear, with
built-in convexity, each N

❂ A4412 Ostomy pouch, drainable, high output, for use on a barrier with
flange (2 piece system), without filter, each N

IOM: 100-02, 15, 120

❂ A4413 Ostomy pouch, drainable, high output, for use on a barrier with
flange (2 piece system), with filter, each N

IOM: 100-02, 15, 120

❂ A4414 Ostomy skin barrier, with flange (solid, flexible, or accordion),
without built-in convexity, 4 × 4 inches or smaller, each
N
IOM: 100-02, 15, 120
❂ A4415 Ostomy skin barrier, with flange (solid, flexible, or accordion),
without built-in convexity, larger than 4 × 4 inches, each
N
IOM: 100-02, 15, 120
✽ A4416 Ostomy pouch, closed, with barrier attached, with filter (1 piece),
each N

✽ A4417 Ostomy pouch, closed, with barrier attached, with built-in

convexity, with filter (1 piece), each N

✽ A4418 Ostomy pouch, closed; without barrier attached, with filter (1 piece),
each N

✽ A4419 Ostomy pouch, closed; for use on barrier with non-locking flange,
with filter (2 piece), each N

✽ A4420 Ostomy pouch, closed; for use on barrier with locking flange (2
piece), each N

✽ A4421 Ostomy supply; miscellaneous N

❂ A4422 Ostomy absorbent material (sheet/pad/crystal packet) for use in

ostomy pouch to thicken liquid stomal output, each N

IOM: 100-02, 15, 120

 ✽ A4423 Ostomy pouch, closed; for use on barrier with locking flange, with
filter (2 piece), each N

✽ A4424 Ostomy pouch, drainable, with barrier attached, with filter (1 piece),
each N

✽ A4425 Ostomy pouch, drainable; for use on barrier with non-locking

flange, with filter (2 piece system), each N

✽ A4426 Ostomy pouch, drainable; for use on barrier with locking flange (2
piece system), each N

✽ A4427 Ostomy pouch, drainable; for use on barrier with locking flange,
with filter (2 piece system), each N

✽ A4428 Ostomy pouch, urinary, with extended wear barrier attached, with
faucet-type tap with valve (1 piece), each N

✽ A4429 Ostomy pouch, urinary, with barrier attached, with built-in

convexity, with faucet-type tap with valve (1 piece), each
N
✽ A4430 Ostomy pouch, urinary, with extended wear barrier attached, with
built-in convexity, with faucet-type tap with valve (1 piece), each
N

✽ A4431 Ostomy pouch, urinary; with barrier attached, with faucet-type tap
with valve (1 piece), each N

✽ A4432 Ostomy pouch, urinary; for use on barrier with non-locking flange,
with faucet-type tap with valve (2 piece), each N

✽ A4433 Ostomy pouch, urinary; for use on barrier with locking flange (2
piece), each N

✽ A4434 Ostomy pouch, urinary; for use on barrier with locking flange, with
faucet-type tap with valve (2 piece), each N

✽ A4435 Ostomy pouch, drainable, high output, with extended wear barrier
(one-piece system), with or without filter, each N

✽ A4436 Irrigation supply; sleeve, reusable, per month N

✽ A4437 Irrigation supply; sleeve, disposable, per month N

Miscellaneous Supplies
❂ A4450 Tape, non-waterproof, per 18 square inches N

If used with surgical dressings, billed with AW modifier (in addition

to appropriate A1-A9 modifier).
IOM: 100-02, 15, 120
❂ A4452 Tape, waterproof, per 18 square inches N
 If used with surgical dressings, billed with AW modifier (in addition
to appropriate A1-A9 modifier).
IOM: 100-02, 15, 120
❂ A4453 Rectal catheter for use with the manual pump-operated enema
system, replacement only N

If used with surgical dressings, billed with AW modifier (in addition

to appropriate A1-A9 modifier).
❂ A4455 Adhesive remover or solvent (for tape, cement or other adhesive),
per ounce N

IOM: 100-02, 15, 120

❂ A4456 Adhesive remover, wipes, any type, each N

May be reimbursed for male or female clients to home health DME

providers and DME medical suppliers in the home setting.
IOM: 100-02, 15, 120
✽ A4458 Enema bag with tubing, reusable N

✽ A4459 Manual pump-operated enema system, includes balloon, catheter

and all accessories, reusable, any type N

✽ A4461 Surgical dressing holder, non-reusable, each N

✽ A4463 Surgical dressing holder, reusable, each N

✽ A4465 Non-elastic binder for extremity N

A4467 Belt, strap, sleeve, garment, or covering, any type E1

❂ A4470 Gravlee jet washer N

Symptoms suggestive of endometrial disease must be present for

this disposable diagnostic tool to be covered.
IOM: 100-02, 16, 90; 100-03, 4, 230.5
❂ A4480 VABRA aspirator N

Symptoms suggestive of endometrial disease must be present for

this disposable diagnostic tool to be covered.
IOM: 100-02, 16, 90; 100-03, 4, 230.6
❂ A4481 Tracheostoma filter, any type, any size, each N

IOM: 100-02, 15, 120

❂ A4483 Moisture exchanger, disposable, for use with invasive mechanical
ventilation N

IOM: 100-02, 15, 120

A4490 Surgical stockings above knee length, each E1
 IOM: 100-02, 15, 100; 100-02, 15, 110; 100-03, 4, 280.1
A4495 Surgical stockings thigh length, each E1

IOM: 100-02, 15, 100; 100-02, 15, 110; 100-03, 4, 280.1

A4500 Surgical stockings below knee length, each E1

IOM: 100-02, 15, 100; 100-02, 15, 110; 100-03, 4, 280.1

A4510 Surgical stockings full length, each E1

IOM: 100-02, 15, 100; 100-02, 15, 110; 100-03, 4, 280.1

A4520 Incontinence garment, any type (e.g., brief, diaper), each
E1
IOM: 100-03, 4, 280.1
❂ A4550 Surgical trays B

No longer payable by Medicare; included in practice expense for

procedures. Some private payers may pay, most private payers
follow Medicare guidelines.
IOM: 100-04, 12, 20.3, 30.4
A4553 Non-disposable underpads, all sizes E1

IOM: 100-03, 4, 280.1

A4554 Disposable underpads, all sizes E1

IOM: 100-03, 4, 280.1

A4555 Electrode/transducer for use with electrical stimulation device used
for cancer treatment, replacement only E1

✽ A4556 Electrodes (e.g., apnea monitor), per pair N

✽ A4557 Lead wires (e.g., apnea monitor), per pair N

✽ A4558 Conductive gel or paste, for use with electrical device (e.g., TENS,
NMES), per oz N

✽ A4559 Coupling gel or paste, for use with ultrasound device, per oz
N
✽ A4561 Pessary, rubber, any type ♀ N

✽ A4562 Pessary, non-rubber, any type ♀ N

✽ A4563 Rectal control system for vaginal insertion, for long term use,
includes pump and all supplies and accessories, any type each N

✽ A4565 Slings N

A4566 Shoulder sling or vest design, abduction restrainer, with or without

swathe control, prefabricated, includes fitting and adjustment
E1
 A4570 Splint E1

IOM: 100-02, 6, 10; 100-02, 15, 100; 100-04, 4, 240

✽ A4575 Topical hyperbaric oxygen chamber, disposable A

A4580 Cast supplies (e.g., plaster) E1

IOM: 100-02, 6, 10; 100-02, 15, 100; 100-04, 4, 240

A4590 Special casting material (e.g., fiberglass) E1

IOM: 100-02, 6, 10; 100-02, 15, 100; 100-04, 4, 240

❂ A4595 Electrical stimulator supplies, 2 lead, per month (e.g., TENS,
NMES) N

IOM: 100-03, 2, 160.13

▶ A4596 Cranial electrotherapy stimulation (CES) system supplies and
accessories, per month
✽ A4600 Sleeve for intermittent limb compression device, replacement only,
each E1

Figure 4 Arm sling.

✽ A4601 Lithium ion battery, rechargeable, for non-prosthetic use,

replacement E1

✽ A4602 Replacement battery for external infusion pump owned by patient,

lithium, 1.5 volt, each N

✽ A4604 Tubing with integrated heating element for use with positive airway
pressure device N

✽ A4605 Tracheal suction catheter, closed system, each N

✽ A4606 Oxygen probe for use with oximeter device, replacement

 N
✽ A4608 Transtracheal oxygen catheter, each N

Supplies for Respiratory and Oxygen Equipment

A4611 Battery, heavy duty; replacement for patient owned ventilator
E1
Medicare Statute 1834(a)(3)(a)
A4612 Battery cables; replacement for patient-owned ventilator E1

Medicare Statute 1834(a)(3)(a)

A4613 Battery charger; replacement for patient-owned ventilator E1

Medicare Statute 1834(a)(3)(a)

✽ A4614 Peak expiratory flow rate meter, hand held N

❂ A4615 Cannula, nasal N

IOM: 100-03, 2, 160.6; 100-04, 20, 100.2

❂ A4616 Tubing (oxygen), per foot N

IOM: 100-03, 2, 160.6; 100-04, 20, 100.2

Figure 5 Nasal cannula.

❂ A4617 Mouth piece N

IOM: 100-03, 2, 160.6; 100-04, 20, 100.2

❂ A4618 Breathing circuits N
 IOM: 100-03, 2, 160.6; 100-04, 20, 100.2
❂ A4619 Face tent N

IOM: 100-03, 2, 160.6; 100-04, 20, 100.2

❂ A4620 Variable concentration mask N

IOM: 100-03, 2, 160.6; 100-04, 20, 100.2

❂ A4623 Tracheostomy, inner cannula N

IOM: 100-02, 15, 120; 100-03, 1, 20.9

✽ A4624 Tracheal suction catheter, any type, other than closed system, each
N

Sterile suction catheters are medically necessary only for

tracheostomy suctioning. Limitations include three suction catheters
per day when covered for medically necessary tracheostomy
suctioning. Assign DX V44.0 or V55.0 on the claim form. (CMS
Manual System, Pub. 100-3, NCD manual, Chapter 1, Section 280-1)
❂ A4625 Tracheostomy care kit for new tracheostomy N

Dressings used with tracheostomies are included in the allowance for

the code. This starter kit is covered after a surgical tracheostomy.
(https://med.noridianmedicare.com/web/jddme/dmepos/tracheostomy-
supplies)
IOM: 100-02, 15, 120
❂ A4626 Tracheostomy cleaning brush, each N

IOM: 100-02, 15, 120

A4627 Spacer, bag, or reservoir, with or without mask, for use with metered
dose inhaler E1

IOM: 100-02, 15, 110

Figure 6 Tracheostomy cannula.

 ✽ A4628 Oropharyngeal suction catheter, each N

No more than three catheters per week are covered for medically
necessary oropharyngeal suctioning because the catheters can be
reused if cleansed and disinfected. (MS Manual System, Pub. 100-3,
NCD manual, Chapter 1, Section 280-1)
❂ A4629 Tracheostomy care kit for established tracheostomy N

IOM: 100-02, 15, 120

Replacement Parts
❂ A4630 Replacement batteries, medically necessary, transcutaneous
electrical stimulator, owned by patient E1

IOM: 100-03, 3, 160.7

✽ A4633 Replacement bulb/lamp for ultraviolet light therapy system, each
E1

✽ A4634 Replacement bulb for therapeutic light box, tabletop model N

❂ A4635 Underarm pad, crutch, replacement, each E1

IOM: 100-03, 4, 280.1

❂ A4636 Replacement, handgrip, cane, crutch, or walker, each E1

IOM: 100-03, 4, 280.1

❂ A4637 Replacement, tip, cane, crutch, walker, each E1

IOM: 100-03, 4, 280.1

✽ A4638 Replacement battery for patient-owned ear pulse generator, each
E1

✽ A4639 Replacement pad for infrared heating pad system, each E1

❂ A4640 Replacement pad for use with medically necessary alternating

pressure pad owned by patient E1

IOM: 100-03, 4, 280.1; 100-08, 5, 5.2.3

Supplies for Radiological Procedures

✽ A4641 Radiopharmaceutical, diagnostic, not otherwise classified N

Is not an applicable tracer for PET scans

✽ A4642 Indium In-111 satumomab pendetide, diagnostic, per study dose, up
to 6 millicuries N

Miscellaneous Supplies
 ✽ A4648 Tissue marker, implantable, any type, each N
Coding Clinic: 2018, Q2, P4,5; 2013, Q3, P9
✽ A4649 Surgical supply miscellaneous N

✽ A4650 Implantable radiation dosimeter, each N

❂ A4651 Calibrated microcapillary tube, each N

IOM: 100-04, 3, 40.3

❂ A4652 Microcapillary tube sealant N

IOM: 100-04, 3, 40.3

Supplies for Dialysis

✽ A4653 Peritoneal dialysis catheter anchoring device, belt, each N

❂ A4657 Syringe, with or without needle, each N

IOM: 100-04, 8, 90.3.2

❂ A4660 Sphygmomanometer/blood pressure apparatus with cuff and
stethoscope N

IOM: 100-04, 8, 90.3.2

❂ A4663 Blood pressure cuff only N

IOM: 100-04, 8, 90.3.2

A4670 Automatic blood pressure monitor E1

IOM: 100-04, 8, 90.3.2

❂ A4671 Disposable cycler set used with cycler dialysis machine, each
B
IOM: 100-04, 8, 90.3.2
❂ A4672 Drainage extension line, sterile, for dialysis, each B

IOM: 100-04, 8, 90.3.2

❂ A4673 Extension line with easy lock connectors, used with dialysis
B
IOM: 100-04, 8, 90.3.2
❂ A4674 Chemicals/antiseptics solution used to clean/sterilize dialysis
equipment, per 8 oz B

IOM: 100-04, 8, 90.3.2

❂ A4680 Activated carbon filters for hemodialysis, each N

IOM: 100-04, 8, 90.3.2

❂ A4690 Dialyzers (artificial kidneys), all types, all sizes, for hemodialysis,
each N
 IOM: 100-04, 8, 90.3.2
❂ A4706 Bicarbonate concentrate, solution, for hemodialysis, per gallon
N
IOM: 100-04, 8, 90.3.2
❂ A4707 Bicarbonate concentrate, powder, for hemodialysis, per packet
N
IOM: 100-04, 8, 90.3.2
❂ A4708 Acetate concentrate solution, for hemodialysis, per gallon
N
IOM: 100-04, 8, 90.3.2
❂ A4709 Acid concentrate, solution, for hemodialysis, per gallon N

IOM: 100-04, 8, 90.3.2

❂ A4714 Treated water (deionized, distilled, or reverse osmosis) for
peritoneal dialysis, per gallon N

IOM: 100-03, 4, 230.7; 100-04, 3, 40.3

❂ A4719 “Y set” tubing for peritoneal dialysis N

IOM: 100-04, 8, 90.3.2

❂ A4720 Dialysate solution, any concentration of dextrose, fluid volume
greater than 249 cc, but less than or equal to 999 cc, for peritoneal
dialysis N

Do not use AX modifier.

IOM: 100-04, 8, 90.3.2
❂ A4721 Dialysate solution, any concentration of dextrose, fluid volume
greater than 999 cc but less than or equal to 1999 cc, for peritoneal
dialysis N

IOM: 100-04, 8, 90.3.2

❂ A4722 Dialysate solution, any concentration of dextrose, fluid volume
greater than 1999 cc but less than or equal to 2999 cc, for peritoneal
dialysis N

IOM: 100-04, 8, 90.3.2

❂ A4723 Dialysate solution, any concentration of dextrose, fluid volume
greater than 2999 cc but less than or equal to 3999 cc, for peritoneal
dialysis N

IOM: 100-04, 8, 90.3.2

❂ A4724 Dialysate solution, any concentration of dextrose, fluid volume
greater than 3999 cc but less than or equal to 4999 cc for peritoneal
dialysis N

IOM: 100-04, 8, 90.3.2

❂ A4725 Dialysate solution, any concentration of dextrose, fluid volume
greater than 4999 cc but less than or equal to 5999 cc, for peritoneal
dialysis N

IOM: 100-04, 8, 90.3.2

❂ A4726 Dialysate solution, any concentration of dextrose, fluid volume
greater than 5999 cc, for peritoneal dialysis N

IOM: 100-04, 8, 90.3.2

✽ A4728 Dialysate solution, non-dextrose containing, 500 ml B

❂ A4730 Fistula cannulation set for hemodialysis, each N

IOM: 100-04, 8, 90.3.2

❂ A4736 Topical anesthetic, for dialysis, per gram N

IOM: 100-04, 8, 90.3.2

❂ A4737 Injectable anesthetic, for dialysis, per 10 ml N

IOM: 100-04, 8, 90.3.2

❂ A4740 Shunt accessory, for hemodialysis, any type, each N

IOM: 100-04, 8, 90.3.2

❂ A4750 Blood tubing, arterial or venous, for hemodialysis, each N

IOM: 100-04, 8, 90.3.2

❂ A4755 Blood tubing, arterial and venous combined, for hemodialysis, each
N

IOM: 100-04, 8, 90.3.2

❂ A4760 Dialysate solution test kit, for peritoneal dialysis, any type, each
N

IOM: 100-04, 8, 90.3.2

❂ A4765 Dialysate concentrate, powder, additive for peritoneal dialysis, per
packet N

IOM: 100-04, 8, 90.3.2

❂ A4766 Dialysate concentrate, solution, additive for peritoneal dialysis, per
10 ml N

IOM: 100-04, 8, 90.3.2

❂ A4770 Blood collection tube, vacuum, for dialysis, per 50 N

IOM: 100-04, 8, 90.3.2

❂ A4771 Serum clotting time tube, for dialysis, per 50 N

IOM: 100-04, 8, 90.3.2

❂ A4772 Blood glucose test strips, for dialysis, per 50 N
 IOM: 100-04, 8, 90.3.2
❂ A4773 Occult blood test strips, for dialysis, per 50 N

IOM: 100-04, 8, 90.3.2

❂ A4774 Ammonia test strips, for dialysis, per 50 N

IOM: 100-04, 8, 90.3.2

❂ A4802 Protamine sulfate, for hemodialysis, per 50 mg N

IOM: 100-04, 8, 90.3.2

❂ A4860 Disposable catheter tips for peritoneal dialysis, per 10 N

IOM: 100-04, 8, 90.3.2

❂ A4870 Plumbing and/or electrical work for home hemodialysis equipment
N

IOM: 100-04, 8, 90.3.2

❂ A4890 Contracts, repair and maintenance, for hemodialysis equipment
N

IOM: 100-02, 15, 110.2

❂ A4911 Drain bag/bottle, for dialysis, each N

❂ A4913 Miscellaneous dialysis supplies, not otherwise specified N

Items not related to dialysis must not be billed with the

miscellaneous codes A4913 or E1699.
❂ A4918 Venous pressure clamp, for hemodialysis, each N

❂ A4927 Gloves, non-sterile, per 100 N

❂ A4928 Surgical mask, per 20 N

❂ A4929 Tourniquet for dialysis, each N

❂ A4930 Gloves, sterile, per pair N

✽ A4931 Oral thermometer, reusable, any type, each N

✽ A4932 Rectal thermometer, reusable, any type, each N

Additional Ostomy Supplies

❂ A5051 Ostomy pouch, closed; with barrier attached (1 piece), each
N

IOM: 100-02, 15, 120

❂ A5052 Ostomy pouch, closed; without barrier attached (1 piece), each
N

IOM: 100-02, 15, 120

❂ A5053 Ostomy pouch, closed; for use on faceplate, each N

IOM: 100-02, 15, 120

❂ A5054 Ostomy pouch, closed; for use on barrier with flange (2 piece), each
N

IOM: 100-02, 15, 120

❂ A5055 Stoma cap N

IOM: 100-02, 15, 120

❂ A5056 Ostomy pouch, drainable, with extended wear barrier attached, with
filter (1 piece), each N

IOM: 100-02, 15, 120

❂ A5057 Ostomy pouch, drainable, with extended wear barrier attached, with
built in convexity, with filter (1 piece), each N

IOM: 100-02, 15, 120

✽ A5061 Ostomy pouch, drainable; with barrier attached (1 piece), each
N

IOM: 100-02, 15, 120

❂ A5062 Ostomy pouch, drainable; without barrier attached (1 piece), each
N

IOM: 100-02, 15, 120

❂ A5063 Ostomy pouch, drainable; for use on barrier with flange (2 piece
system), each N

IOM: 100-02, 15, 120

❂ A5071 Ostomy pouch, urinary; with barrier attached (1 piece), each
N

IOM: 100-02, 15, 120

❂ A5072 Ostomy pouch, urinary; without barrier attached (1 piece), each
N

IOM: 100-02, 15, 120

❂ A5073 Ostomy pouch, urinary; for use on barrier with flange (2 piece),
each N

IOM: 100-02, 15, 120

❂ A5081 Stoma plug or seal, any type N

IOM: 100-02, 15, 120

❂ A5082 Continent device; catheter for continent stoma N

IOM: 100-02, 15, 120

✽ A5083 Continent device, stoma absorptive cover for continent stoma
 N

❂ A5093 Ostomy accessory; convex insert N

IOM: 100-02, 15, 120

Additional Incontinence and Ostomy Supplies

❂ A5102 Bedside drainage bottle with or without tubing, rigid or expandable,
each N

IOM: 100-02, 15, 120

❂ A5105 Urinary suspensory, with leg bag, with or without tube, each
N

IOM: 100-02, 15, 120

❂ A5112 Urinary drainage bag, leg bag, leg or abdomen, latex, with or
without tube, with straps, each N

IOM: 100-02, 15, 120

❂ A5113 Leg strap; latex, replacement only, per set E1

IOM: 100-02, 15, 120

❂ A5114 Leg strap; foam or fabric, replacement only, per set
E1
IOM: 100-02, 15, 120
❂ A5120 Skin barrier, wipes or swabs, each N

IOM: 100-02, 15, 120

❂ A5121 Skin barrier; solid, 6 × 6 or equivalent, each N

IOM: 100-02, 15, 120

❂ A5122 Skin barrier; solid, 8 × 8 or equivalent, each N

IOM: 100-02, 15, 120

❂ A5126 Adhesive or non-adhesive; disk or foam pad N

IOM: 100-02, 15, 120

❂ A5131 Appliance cleaner, incontinence and ostomy appliances, per 16 oz
N

IOM: 100-02, 15, 120

❂ A5200 Percutaneous catheter/tube anchoring device, adhesive skin
attachment N

IOM: 100-02, 15, 120

Diabetic Shoes, Fitting, and Modifications

❂ A5500 For diabetics only, fitting (including follow-up), custom preparation
 and supply of off-the-shelf depth-inlay shoe manufactured to
accommodate multi-density insert(s), per shoe Y

IOM: 100-02, 15, 140

❂ A5501 For diabetics only, fitting (including follow-up), custom preparation
and supply of shoe molded from cast(s) of patient’s foot (custom-
molded shoe), per shoe Y

The diabetic patient must have at least one of the following

conditions: peripheral neuropathy with evidence of callus formation,
pre-ulcerative calluses, previous ulceration, foot deformity, previous
amputation or poor circulation.
IOM: 100-02, 15, 140
❂ A5503 For diabetics only, modification (including fitting) of off-the-shelf
depth-inlay shoe or custom-molded shoe with roller or rigid rocker
bottom, per shoe Y

IOM: 100-02, 15, 140

❂ A5504 For diabetics only, modification (including fitting) of off-the-shelf
depth-inlay shoe or custom-molded shoe with wedge(s), per shoe
Y

IOM: 100-02, 15, 140

❂ A5505 For diabetics only, modification (including fitting) of off-the-shelf
depth-inlay shoe or custom-molded shoe with metatarsal bar, per
shoe Y

IOM: 100-02, 15, 140

❂ A5506 For diabetics only, modification (including fitting) of off-the-shelf
depth-inlay shoe or custom-molded shoe with off-set heel(s), per
shoe Y

IOM: 100-02, 15, 140

❂ A5507 For diabetics only, not otherwise specified modification (including
fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe, per
shoe Y

Only used for not otherwise specified therapeutic modifications to

shoe or for repairs to a diabetic shoe(s)
IOM: 100-02, 15, 140
❂ A5508 For diabetics only, deluxe feature of off-the-shelf depth-inlay shoe
or custom-molded shoe, per shoe Y

IOM: 100-02, 15, 40

❂ A5510 For diabetics only, direct formed, compression molded to patient’s
 foot without external heat source, multiple-density insert(s)
prefabricated, per shoe N

IOM: 100-02, 15, 140

✽ A5512 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 durometer (or higher), prefabricated, each Y

✽ A5513 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 higher), includes arch filler and other shaping
material, custom fabricated, each Y

❂ A5514 For diabetics only, multiple density insert, made by direct carving
with cam technology from a rectified CAD model created from a
digitized scan of the patient, total contact with patient’s foot,
including arch, base layer minimum of 3/16 inch material of shore a
35 durometer (or higher), includes arch filler and other shaping
material, custom fabricated, each Y

Dressings
A6000 Non-contact wound warming wound cover for use with the non-
contact wound warming device and warming card E1

IOM: 100-02, 16, 20

❂ A6010 Collagen based wound filler, dry form, sterile, per gram of collagen
N

IOM: 100-02, 15, 100

❂ A6011 Collagen based wound filler, gel/paste, per gram of collagen
N
IOM: 100-02, 15, 100
❂ A6021 Collagen dressing, sterile, size 16 sq. in. or less, each N

IOM: 100-02, 15, 100

❂ A6022 Collagen dressing, sterile, size more than 16 sq. in. but less than or
equal to 48 sq. in., each N

IOM: 100-02, 15, 100

❂ A6023 Collagen dressing, sterile, size more than 48 sq. in., each N

IOM: 100-02, 15, 100

❂ A6024 Collagen dressing wound filler, sterile, per 6 inches N
 IOM: 100-02, 15, 100
✽ A6025 Gel sheet for dermal or epidermal application (e.g., silicone,
hydrogel, other), each N

If used for the treatment of keloids or other scars, a silicone gel

sheet will not meet the definition of the surgical dressing benefit and
will be denied as noncovered.
❂ A6154 Wound pouch, each N

Waterproof collection device with drainable port that adheres to skin

around wound. Usual dressing change is up to 3 times per week.
IOM: 100-02, 15, 100
❂ A6196 Alginate or other fiber gelling dressing, wound cover, sterile, pad
size 16 sq. in. or less, each dressing N

IOM: 100-02, 15, 100

❂ A6197 Alginate or other fiber gelling dressing, wound cover, sterile, pad
size more than 16 sq. in., but less than or equal to 48 sq. in., each
dressing N

IOM: 100-02, 15, 100

❂ A6198 Alginate or other fiber gelling dressing, wound cover, sterile, pad
size more than 48 sq. in., each dressing N

IOM: 100-02, 15, 100

❂ A6199 Alginate or other fiber gelling dressing, wound filler, sterile, per 6
inches N

IOM: 100-02, 15, 100

❂ A6203 Composite dressing, sterile, pad size 16 sq. in. or less, with any size
adhesive border, each dressing N

Usual composite dressing change is up to 3 times per week, one

wound cover per dressing change.
IOM: 100-02, 15, 100
❂ A6204 Composite dressing, sterile, pad size more than 16 sq. in. but less
than or equal to 48 sq. in., with any size adhesive border, each
dressing N

Usual composite dressing change is up to 3 times per week, one

wound cover per dressing change.
IOM: 100-02, 15, 100
❂ A6205 Composite dressing, sterile, pad size more than 48 sq. in., with any
size adhesive border, each dressing N

Usual composite dressing change is up to 3 times per week, one

 wound cover per dressing change.
IOM: 100-02, 15, 100
❂ A6206 Contact layer, sterile, 16 sq. in. or less, each dressing N

Contact layers are porous to allow wound fluid to pass through for
absorption by separate overlying dressing and are not intended to be
changed with each dressing change. Usual dressing change is up to
once per week.
IOM: 100-02, 15, 100
❂ A6207 Contact layer, sterile, more than 16 sq. in. but less than or equal to
48 sq. in., each dressing N

Contact layer dressings are used to line the entire wound; they are
not intended to be changed with each dressing change. Usual
dressing change is up to once per week.
IOM: 100-02, 15, 100
❂ A6208 Contact layer, sterile, more than 48 sq. in., each dressing N

Contact layer dressings are used to line the entire wound; they are
not intended to be changed with each dressing change. Usual
dressing change is up to once per week.
IOM: 100-02, 15, 100
❂ A6209 Foam dressing, wound cover, sterile, pad size 16 sq. in. or less,
without adhesive border, each dressing N

Made of open cell, medical grade expanded polymer; with

nonadherent property over wound site.
IOM: 100-02, 15, 100
❂ A6210 Foam dressing, wound cover, sterile, pad size more than 16 sq. in.
but less than or equal to 48 sq. in., without adhesive border, each
dressing N

Foam dressings are covered items when used on full thickness

wounds (e.g., stage III or IV ulcers) with moderate to heavy
exudates. Usual dressing change for a foam wound cover when used
as primary dressing is up to 3 times per week. When foam wound
cover is used as a secondary dressing for wounds with very heavy
exudates, dressing change may be up to 3 times per week. Usual
dressing change for foam wound fillers is up to once per day
(A6209-A6215).
IOM: 100-02, 15, 100
❂ A6211 Foam dressing, wound cover, sterile, pad size more than 48 sq. in.,
without adhesive border, each dressing N
 IOM: 100-02, 15, 100
❂ A6212 Foam dressing, wound cover, sterile, pad size 16 sq. in. or less, with
any size adhesive border, each dressing N

IOM: 100-02, 15, 100

❂ A6213 Foam dressing, wound cover, sterile, pad size more than 16 sq. in.
but less than or equal to 48 sq. in., with any size adhesive border,
each dressing N

IOM: 100-02, 15, 100

❂ A6214 Foam dressing, wound cover, sterile, pad size more than 48 sq. in.,
with any size adhesive border, each dressing N

IOM: 100-02, 15, 100

❂ A6215 Foam dressing, wound filler, sterile, per gram N

IOM: 100-02, 15, 100

❂ A6216 Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less,
without adhesive border, each dressing N

IOM: 100-02, 15, 100

❂ A6217 Gauze, non-impregnated, non-sterile, pad size more than 16 sq. in.
but less than or equal to 48 sq. in., without adhesive border, each
dressing N

IOM: 100-02, 15, 100

❂ A6218 Gauze, non-impregnated, non-sterile, pad size more than 48 sq. in.,
without adhesive border, each dressing N

IOM: 100-02, 15, 100

❂ A6219 Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, with any
size adhesive border, each dressing N

IOM: 100-02, 15, 100

❂ A6220 Gauze, non-impregnated, sterile, pad size more than 16 sq. in. but
less than or equal to 48 sq. in., with any size adhesive border, each
dressing N

IOM: 100-02, 15, 100

❂ A6221 Gauze, non-impregnated, sterile, pad size more than 48 sq. in., with
any size adhesive border, each dressing N

IOM: 100-02, 15, 100

❂ A6222 Gauze, impregnated with other than water, normal saline, or
hydrogel, sterile, pad size 16 sq. in. or less, without adhesive border,
each dressing N

Substances may have been incorporated into dressing material (i.e.,

 iodinated agents, petrolatum, zinc paste, crystalline sodium chloride,
chlorhexadine gluconate [CHG], bismuth tribromophenate [BTP],
water, aqueous saline, hydrogel, or agents).
IOM: 100-02, 15, 100
❂ A6223 Gauze, impregnated with other than water, normal saline, or
hydrogel, sterile, pad size more than 16 sq. in. but less than or equal
to 48 sq. in., without adhesive border, each dressing N

IOM: 100-02, 15, 100

❂ A6224 Gauze, impregnated with other than water, normal saline, or
hydrogel, sterile, pad size more than 48 sq. in., without adhesive
border, each dressing N

IOM: 100-02, 15, 100

❂ A6228 Gauze, impregnated, water or normal saline, sterile, pad size 16 sq.
in. or less, without adhesive border, each dressing N

IOM: 100-02, 15, 100

❂ A6229 Gauze, impregnated, water or normal saline, sterile, pad size more
than 16 sq. in. but less than or equal to 48 sq. in., without adhesive
border, each dressing N

IOM: 100-02, 15, 100

❂ A6230 Gauze, impregnated, water or normal saline, sterile, pad size more
than 48 sq. in., without adhesive border, each dressing
N
IOM: 100-02, 15, 100
❂ A6231 Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad
size 16 sq. in. or less, each dressing N

IOM: 100-02, 15, 100

❂ A6232 Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad
size greater than 16 sq. in., but less than or equal to 48 sq. in., each
dressing N

IOM: 100-02, 15, 100

❂ A6233 Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad
size more than 48 sq. in., each dressing N

IOM: 100-02, 15, 100

❂ A6234 Hydrocolloid dressing, wound cover, sterile, pad size 16 sq. in. or
less, without adhesive border, each dressing N

This type of dressing is usually used on wounds with light to

moderate exudate with an average of three dressing changes per
week.
 IOM: 100-02, 15, 100
❂ A6235 Hydrocolloid dressing, wound cover, sterile, pad size more than 16
sq. in. but less than or equal to 48 sq. in., without adhesive border,
each dressing N

IOM: 100-02, 15, 100

❂ A6236 Hydrocolloid dressing, wound cover, sterile, pad size more than 48
sq. in., without adhesive border, each dressing N

IOM: 100-02, 15, 100

❂ A6237 Hydrocolloid dressing, wound cover, sterile, pad size 16 sq. in. or
less, with any size adhesive border, each dressing N

IOM: 100-02, 15, 100

❂ A6238 Hydrocolloid dressing, wound cover, sterile, pad size more than 16
sq. in. but less than or equal to 48 sq. in., with any size adhesive
border, each dressing N

IOM: 100-02, 15, 100

❂ A6239 Hydrocolloid dressing, wound cover, sterile, pad size more than 48
sq. in., with any size adhesive border, each dressing N

IOM: 100-02, 15, 100

❂ A6240 Hydrocolloid dressing, wound filler, paste, sterile, per ounce
N

IOM: 100-02, 15, 100

❂ A6241 Hydrocolloid dressing, wound filler, dry form, sterile, per gram
N

IOM: 100-02, 15, 100

❂ A6242 Hydrogel dressing, wound cover, sterile, pad size 16 sq. in. or less,
without adhesive border, each dressing N

Considered medically necessary when used on full thickness

wounds with minimal or no exudate (e.g., stage III or IV ulcers).
Usually up to one dressing change per day is considered medically
necessary, but if well documented and medically necessary, the
payer may allow more frequent dressing changes.
IOM: 100-02, 15, 100
❂ A6243 Hydrogel dressing, wound cover, sterile, pad size more than 16 sq.
in. but less than or equal to 48 sq. in., without adhesive border, each
dressing N

IOM: 100-02, 15, 100

❂ A6244 Hydrogel dressing, wound cover, sterile, pad size more than 48 sq.
 in., without adhesive border, each dressing N

IOM: 100-02, 15, 100

❂ A6245 Hydrogel dressing, wound cover, sterile, pad size 16 sq. in. or less,
with any size adhesive border, each dressing N

Coverage of a non-elastic gradient compression wrap is limited to

one per 6 months per leg.
IOM: 100-02, 15, 100
❂ A6246 Hydrogel dressing, wound cover, sterile, pad size more than 16 sq.
in. but less than or equal to 48 sq. in., with any size adhesive border,
each dressing N

IOM: 100-02, 15, 100

❂ A6247 Hydrogel dressing, wound cover, sterile, pad size more than 48 sq.
in., with any size adhesive border, each dressing N

IOM: 100-02, 15, 100

❂ A6248 Hydrogel dressing, wound filler, gel, per fluid ounce N

IOM: 100-02, 15, 100

❂ A6250 Skin sealants, protectants, moisturizers, ointments, any type, any
size N

IOM: 100-02, 15, 100

❂ A6251 Specialty absorptive dressing, wound cover, sterile, pad size 16 sq.
in. or less, without adhesive border, each dressing N

IOM: 100-02, 15, 100

❂ A6252 Specialty absorptive dressing, wound cover, sterile, pad size more
than 16 sq. in. but less than or equal to 48 sq. in., without adhesive
border, each dressing N

IOM: 100-02, 15, 100

❂ A6253 Specialty absorptive dressing, wound cover, sterile, pad size more
than 48 sq. in., without adhesive border, each dressing N

IOM: 100-02, 15, 100

❂ A6254 Specialty absorptive dressing, wound cover, sterile, pad size 16 sq.
in. or less, with any size adhesive border, each dressing
N
IOM: 100-02, 15, 100
❂ A6255 Specialty absorptive dressing, wound cover, sterile, pad size more
than 16 sq. in. but less than or equal to 48 sq. in., with any size
adhesive border, each dressing N

IOM: 100-02, 15, 100

❂ A6256 Specialty absorptive dressing, wound cover, sterile, pad size more
than 48 sq. in., with any size adhesive border, each dressing
N
Considered medically necessary when used for moderately or highly
exudative wounds (e.g., stage III or IV ulcers).
IOM: 100-02, 15, 100
❂ A6257 Transparent film, sterile, 16 sq. in. or less, each dressing
N
Considered medically necessary when used on open partial
thickness wounds with minimal exudate or closed wounds.
IOM: 100-02, 15, 100
❂ A6258 Transparent film, sterile, more than 16 sq. in. but less than or equal
to 48 sq. in., each dressing N

IOM: 100-02, 15, 100

❂ A6259 Transparent film, sterile, more than 48 sq. in., each dressing
N

IOM: 100-02, 15, 100

❂ A6260 Wound cleansers, any type, any size N

IOM: 100-02, 15, 100

❂ A6261 Wound filler, gel/paste, per fluid ounce, not otherwise specified
N

Units of service for wound fillers are 1 gram, 1 fluid ounce, 6 inch
length, or 1 yard depending on product.
IOM: 100-02, 15, 100
❂ A6262 Wound filler, dry form, per gram, not otherwise specified
Dry forms (e.g., powder, granules, beads) are used to eliminate N
dead space in an open wound.
IOM: 100-02, 15, 100
❂ A6266 Gauze, impregnated, other than water, normal saline, or zinc paste,
sterile, any width, per linear yard N

IOM: 100-02, 15, 100

❂ A6402 Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, without
adhesive border, each dressing N

IOM: 100-02, 15, 100

❂ A6403 Gauze, non-impregnated, sterile, pad size more than 16 sq. in., less
than or equal to 48 sq. in., without adhesive border, each dressing
N

IOM: 100-02, 15, 100

 ❂ A6404 Gauze, non-impregnated, sterile, pad size more than 48 sq. in.,
without adhesive border, each dressing N

IOM: 100-02, 15, 100

✽ A6407 Packing strips, non-impregnated, sterile, up to 2 inches in width, per
linear yard N

IOM: 100-02, 15, 100

❂ A6410 Eye pad, sterile, each N

IOM: 100-02, 15, 100

❂ A6411 Eye pad, non-sterile, each N

IOM: 100-02, 15, 100

✽ A6412 Eye patch, occlusive, each N

Bandages
A6413 Adhesive bandage, first-aid type, any size, each E1

First aid type bandage is a wound cover with a pad size of less than
4 sq. in. Does not meet the definition of the surgical dressing benefit
and will be denied as non-covered.
Medicare Statute 1861(s)(5)
✽ A6441 Padding bandage, non-elastic, nonwoven/non-knitted, width greater
than or equal to three inches and less than five inches, per yard
N
✽ A6442 Conforming bandage, non-elastic, knitted/woven, non-sterile, width
less than three inches, per yard N

Non-elastic, moderate or high compression that is typically

sustained for one week
✽ A6443 Conforming bandage, non-elastic, knitted/woven, non-sterile, width
greater than or equal to three inches and less than five inches, per
yard N

✽ A6444 Conforming bandage, non-elastic, knitted/woven, non-sterile, width

greater than or equal to five inches, per yard N

✽ A6445 Conforming bandage, non-elastic, knitted/woven, sterile, width less

than three inches, per yard N

✽ A6446 Conforming bandage, non-elastic, knitted/woven, sterile, width

greater than or equal to three inches and less than five inches, per
yard N

✽ A6447 Conforming bandage, non-elastic, knitted/woven, sterile, width

greater than or equal to five inches, per yard N
✽ A6448 Light compression bandage, elastic, knitted/woven, width less than
three inches, per yard N

Used to hold wound cover dressings in place over a wound.

Example is an ACE type elastic bandage.
✽ A6449 Light compression bandage, elastic, knitted/woven, width greater
than or equal to three inches and less than five inches, per yard
N
✽ A6450 Light compression bandage, elastic, knitted/woven, width greater
than or equal to five inches, per yard N

✽ A6451 Moderate compression bandage, elastic, knitted/woven, load

resistance of 1.25 to 1.34 foot pounds at 50% maximum stretch,
width greater than or equal to three inches and less than five inches,
per yard N

Elastic bandages that produce moderate compression that is

typically sustained for one week
Medicare considers coverage if part of a multi-layer compression
bandage system for the treatment of a venous stasis ulcer. Do not
assign for strains or sprains.
✽ A6452 High compression bandage, elastic, knitted/woven, load resistance
greater than or equal to 1.35 foot pounds at 50% maximum stretch,
width greater than or equal to three inches and less than five inches,
per yard N

Elastic bandages that produce high compression that is typically

sustained for one week
✽ A6453 Self-adherent bandage, elastic, non-knitted/non-woven, width less
than three inches, per yard N

✽ A6454 Self-adherent bandage, elastic, non-knitted/non-woven, width

greater than or equal to three inches and less than five inches, per
yard N

✽ A6455 Self-adherent bandage, elastic, non-knitted/non-woven, width

greater than or equal to five inches, per yard N

✽ A6456 Zinc paste impregnated bandage, non-elastic, knitted/woven, width

greater than or equal to three inches and less than five inches, per
yard N

✽ A6457 Tubular dressing with or without elastic, any width, per linear yard
N

✽ A6460 Synthetic resorbable wound dressing, sterile, pad size 16 sq. in. or
less, without adhesive border, each dressing N
✽ A6461 Synthetic resorbable wound dressing, sterile, pad size more than 16
sq. in. but less than or equal to 48 sq. in., without adhesive border,
each dressing N
Compression Garments
❂ A6501 Compression burn garment, bodysuit (head to foot), custom
fabricated N

Garments used to reduce hypertrophic scarring and joint

contractures following burn injury
IOM: 100-02, 15, 100
❂ A6502 Compression burn garment, chin strap, custom fabricated
N
IOM: 100-02, 15, 100
❂ A6503 Compression burn garment, facial hood, custom fabricated
N

IOM: 100-02, 15, 100

❂ A6504 Compression burn garment, glove to wrist, custom fabricated
N

IOM: 100-02, 15, 100

❂ A6505 Compression burn garment, glove to elbow, custom fabricated
N

IOM: 100-02, 15, 100

❂ A6506 Compression burn garment, glove to axilla, custom fabricated
N

IOM: 100-02, 15, 100

❂ A6507 Compression burn garment, foot to knee length, custom fabricated
N

IOM: 100-02, 15, 100

❂ A6508 Compression burn garment, foot to thigh length, custom fabricated
N

IOM: 100-02, 15, 100

❂ A6509 Compression burn garment, upper trunk to waist including arm
openings (vest), custom fabricated N

IOM: 100-02, 15, 100

❂ A6510 Compression burn garment, trunk, including arms down to leg
openings (leotard), custom fabricated N

IOM: 100-02, 15, 100

❂ A6511 Compression burn garment, lower trunk including leg openings
(panty), custom fabricated N
 IOM: 100-02, 15, 100
❂ A6512 Compression burn garment, not otherwise classified N

IOM: 100-02, 15, 100

✽ A6513 Compression burn mask, face and/or neck, plastic or equal, custom
fabricated B

A6530 Gradient compression stocking, below knee, 18-30 mmHg, each

E1

IOM: 100-03, 4, 280.1

❂ A6531 Gradient compression stocking, below knee, 30-40 mmHg, each
N

Covered when used in treatment of open venous stasis ulcer.

Modifiers A1-A9 are not assigned. Must be billed with AW, RT, or
LT.
IOM: 100-02, 15, 100
❂ A6532 Gradient compression stocking, below knee, 40-50 mmHg, each
N

Covered when used in treatment of open venous stasis ulcer.

Modifiers A1-A9 are not assigned. Must be billed with AW, RT, or
LT.
IOM: 100-02, 15, 100
A6533 Gradient compression stocking, thigh length, 18-30 mmHg, each
E1

IOM: 100-02, 15, 130; 100-03, 4, 280.1

A6534 Gradient compression stocking, thigh length, 30-40 mmHg, each
E1

IOM: 100-02, 15, 130; 100-03, 4, 280.1

A6535 Gradient compression stocking, thigh length, 40-50 mmHg, each
E1

IOM: 100-02, 15, 130; 100-03, 4, 280.1

A6536 Gradient compression stocking, full length/chap style, 18-30 mmHg,
each E1

IOM: 100-02, 15, 130; 100-03, 4, 280.1

A6537 Gradient compression stocking, full length/chap style, 30-40 mmHg,
each E1

IOM: 100-02, 15, 130; 100-03, 4, 280.1

A6538 Gradient compression stocking, full length/chap style, 40-50 mmHg,
each E1
 IOM: 100-02, 15, 130; 100-03, 4, 280.1
A6539 Gradient compression stocking, waist length, 18-30 mmHg, each
E1

IOM: 100-02, 15, 130; 100-03, 4, 280.1

A6540 Gradient compression stocking, waist length, 30-40 mmHg, each
E1

IOM: 100-02, 15, 130; 100-03, 4, 280.1

A6541 Gradient compression stocking, waist length, 40-50 mmHg, each
E1

IOM: 100-02, 15, 130; 100-03, 4, 280.1

A6544 Gradient compression stocking, garter belt E1

IOM: 100-02, 15, 130; 100-03, 4, 280.1

❂ A6545 Gradient compression wrap, non-elastic, below knee, 30-50 mm hg,
each N

Modifiers RT and/or LT must be appended. When assigned for

bilateral items (left/right) on the same date of service, bill both items
on the same claim line using RT/LT modifiers and 2 units of service.
IOM: 10-02, 15, 100
A6549 Gradient compression stocking/sleeve, not otherwise specified
E1
IOM: 100-02, 15, 130; 100-03, 4, 280.1

Wound Care
✽ A6550 Wound care set, for negative pressure wound therapy electrical
pump, includes all supplies and accessories N

Respiratory Supplies
✽ A7000 Canister, disposable, used with suction pump, each Y

✽ A7001 Canister, non-disposable, used with suction pump, each Y

✽ A7002 Tubing, used with suction pump, each Y

✽ A7003 Administration set, with small volume nonfiltered pneumatic

nebulizer, disposable Y

✽ A7004 Small volume nonfiltered pneumatic nebulizer, disposable

Y
✽ A7005 Administration set, with small volume nonfiltered pneumatic
nebulizer, nondisposable Y

Administration set, with small volume filtered pneumatic nebulizer

✽ A7006 Y

✽ A7007 Large volume nebulizer, disposable, unfilled, used with aerosol

compressor Y

✽ A7008 Large volume nebulizer, disposable, prefilled, used with aerosol

compressor Y

✽ A7009 Reservoir bottle, nondisposable, used with large volume ultrasonic

nebulizer Y

✽ A7010 Corrugated tubing, disposable, used with large volume nebulizer,

100 feet Y

✽ A7012 Water collection device, used with large volume nebulizer

Y
✽ A7013 Filter, disposable, used with aerosol compressor or ultrasonic
generator Y

✽ A7014 Filter, non-disposable, used with aerosol compressor or ultrasonic

generator Y

✽ A7015 Aerosol mask, used with DME nebulizer Y

✽ A7016 Dome and mouthpiece, used with small volume ultrasonic nebulizer
Y

❂ A7017 Nebulizer, durable, glass or autoclavable plastic, bottle type, not

used with oxygen Y

IOM: 100-03, 4, 280.1

✽ A7018 Water, distilled, used with large volume nebulizer, 1000 ml
Y
✽ A7020 Interface for cough stimulating device, includes all components,
replacement only Y

✽ A7025 High frequency chest wall oscillation system vest, replacement for
use with patient owned equipment, each N

✽ A7026 High frequency chest wall oscillation system hose, replacement for
use with patient owned equipment, each Y

✽ A7027 Combination oral/nasal mask, used with continuous positive airway

pressure device, each Y

✽ A7028 Oral cushion for combination oral/nasal mask, replacement only,

each Y

✽ A7029 Nasal pillows for combination oral/nasal mask, replacement only,

pair Y

✽ A7030 Full face mask used with positive airway pressure device, each
Y
✽ A7031 Face mask interface, replacement for full face mask, each
Y
 ✽ A7032 Cushion for use on nasal mask interface, replacement only, each
Y

✽ A7033 Pillow for use on nasal cannula type interface, replacement only,
pair Y

✽ A7034 Nasal interface (mask or cannula type) used with positive airway
pressure device, with or without head strap Y

✽ A7035 Headgear used with positive airway pressure device Y

✽ A7036 Chinstrap used with positive airway pressure device Y

✽ A7037 Tubing used with positive airway pressure device Y

✽ A7038 Filter, disposable, used with positive airway pressure device

Y
✽ A7039 Filter, non disposable, used with positive airway pressure device
Y

✽ A7040 One way chest drain valve N

✽ A7041 Water seal drainage container and tubing for use with implanted
chest tube N

✽ A7044 Oral interface used with positive airway pressure device, each
Y

❂ A7045 Exhalation port with or without swivel used with accessories for
positive airway devices, replacement only Y

IOM: 100-03, 4, 230.17

❂ A7046 Water chamber for humidifier, used with positive airway pressure
device, replacement, each Y

IOM: 100-03, 4, 230.17

✽ A7047 Oral interface used with respiratory suction pump, each
N
✽ A7048 Vacuum drainage collection unit and tubing kit, including all
supplies needed for collection unit change, for use with implanted
catheter, each N

Tracheostomy Supplies
❂ A7501 Tracheostoma valve, including diaphragm, each N

IOM: 100-02, 15, 120

❂ A7502 Replacement diaphragm/faceplate for tracheostoma valve, each
N

IOM: 100-02, 15, 120

❂ A7503 Filter holder or filter cap, reusable, for use in a tracheostoma heat
 and moisture exchange system, each N

IOM: 100-02, 15, 120

❂ A7504 Filter for use in a tracheostoma heat and moisture exchange system,
each N

IOM: 100-02, 15, 120

❂ A7505 Housing, reusable without adhesive, for use in a heat and moisture
exchange system and/or with a tracheostoma valve, each N

IOM: 100-02, 15, 120

❂ A7506 Adhesive disc for use in a heat and moisture exchange system
and/or with tracheostoma valve, any type, each N

IOM: 100-02, 15, 120

❂ A7507 Filter holder and integrated filter without adhesive, for use in a
tracheostoma heat and moisture exchange system, each
N
IOM: 100-02, 15, 120
❂ A7508 Housing and integrated adhesive, for use in a tracheostoma heat and
moisture exchange system and/or with a tracheostoma valve, each
N

IOM: 100-02, 15, 120

❂ A7509 Filter holder and integrated filter housing, and adhesive, for use as a
tracheostoma heat and moisture exchange system, each N

IOM: 100-02, 15, 120

✽ A7520 Tracheostomy/laryngectomy tube, noncuffed, polyvinylchloride
(PVC), silicone or equal, each N

✽ A7521 Tracheostomy/laryngectomy tube, cuffed, polyvinylchloride (PVC),

silicone or equal, each N

✽ A7522 Tracheostomy/laryngectomy tube, stainless steel or equal

(sterilizable and reusable), each N

✽ A7523 Tracheostomy shower protector, each N

✽ A7524 Tracheostoma stent/stud/button, each N

✽ A7525 Tracheostomy mask, each N

✽ A7526 Tracheostomy tube collar/holder, each N

✽ A7527 Tracheostomy/laryngectomy tube plug/stop, each N

Figure 7 Helmet.

Helmets
✽ A8000 Helmet, protective, soft, prefabricated, includes all components and
accessories Y

✽ A8001 Helmet, protective, hard, prefabricated, includes all components and

accessories Y

✽ A8002 Helmet, protective, soft, custom fabricated, includes all components

and accessories Y

✽ A8003 Helmet, protective, hard, custom fabricated, includes all

components and accessories Y

✽ A8004 Soft interface for helmet, replacement only Y

ADMINISTRATIVE, MISCELLANEOUS, AND

INVESTIGATIONAL (A9000-A9999)
NOTE: The following codes do not imply that codes in other sections are
necessarily covered.

Miscellaneous Supplies
❂ A9150 Non-prescription drugs B

IOM: 100-02, 15, 50

A9152 Single vitamin/mineral/trace element, oral, per dose, not otherwise
specified E1

A9153 Multiple vitamins, with or without minerals and trace elements, oral,
per dose, not otherwise specified E1

✽ A9155 Artificial saliva, 30 ml B

Pediculosis (lice infestation) treatment, topical, for administration

A9180 by patient/caretaker E1

A9270 Non-covered item or service E1

IOM: 100-02, 16, 20

A9272 Wound suction, disposable, includes dressing, all accessories and
components, any type, each E1

Medicare Statute 1861(n)

A9273 Cold or hot water bottle, ice cap or collar, heat and/or cold wrap,
any type E1

A9274 External ambulatory insulin delivery system, disposable, each,

includes all supplies and accessories E1

Medicare Statute 1861(n)

A9275 Home glucose disposable monitor, includes test strips E1

A9276 Sensor; invasive (e.g., subcutaneous), disposable, for use with non-
durable medical equipment interstitial continuous glucose
monitoring system, one unit = 1 day supply E1

Medicare Statute 1861(n)

A9277 Transmitter; external, for use with nondurable medical equipment
interstitial continuous glucose monitoring system E1

Medicare Statute 1861(n)

A9278 Receiver (monitor); external, for use with non-durable medical
equipment interstitial continuous glucose monitoring system
E1
Medicare Statute 1861(n)
A9279 Monitoring feature/device, stand-alone or integrated, any type,
includes all accessories, components and electronics, not otherwise
classified E1

Medicare Statute 1861(n)

A9280 Alert or alarm device, not otherwise classified E1

Medicare Statute 1861

A9281 Reaching/grabbing device, any type, any length, each E1

Medicare Statute 1862 SSA

A9282 Wig, any type, each E1

Medicare Statute 1862 SSA

A9283 Foot pressure off loading/supportive device, any type, each
E1
Medicare Statute 1862A(i)13
❂ A9284 Spirometer, non-electronic, includes all accessories N
 ✽ A9285 Inversion/eversion correction device A

A9286 Hygienic item or device, disposable or non-disposable, any type,

each E1

Medicare Statute 1834

A9300 Exercise equipment E1

IOM: 100-02, 15, 110.1; 100-03, 4, 280.1

Supplies for Radiology Procedures (Radiopharmaceuticals)

✽ A9500 Technetium Tc-99m sestamibi, diagnostic, per study dose
N1 N
Should be filed on same claim as procedure code reporting
radiopharmaceutical. Verify with payer definition of a “study.”
Coding Clinic: 2006, Q2, P5
✽ A9501 Technetium Tc-99m teboroxime, diagnostic, per study dose
N1 N
✽ A9502 Technetium Tc-99m tetrofosmin, diagnostic, per study dose
Coding Clinic: 2006, Q2, P5 N1 N

✽ A9503 Technetium Tc-99m medronate, diagnostic, per study dose, up to 30

millicuries N1 N

✽ A9504 Technetium Tc-99m apcitide, diagnostic, per study dose, up to 20

millicuries N1 N

✽ A9505 Thallium Tl-201 thallous chloride, diagnostic, per millicurie

N1 N
✽ A9507 Indium In-111 capromab pendetide, diagnostic, per study dose, up to
10 millicuries N1 N

✽ A9508 Iodine I-131 iobenguane sulfate, diagnostic, per 0.5 millicurie

N1 N
✽ A9509 Iodine I-123 sodium iodide, diagnostic, per millicurie
N1 N
✽ A9510 Technetium Tc-99m disofenin, diagnostic, per study dose, up to 15
millicuries N1 N

✽ A9512 Technetium Tc-99m pertechnetate, diagnostic, per millicurie

N1 N
❂ A9513 Lutetium lu 177, dotatate, therapeutic, 1 millicurie G

✽ A9515 Choline C-11, diagnostic, per study dose up to 20 millicuries

K2 G
✽ A9516 Iodine I-123 sodium iodide, diagnostic, per 100 microcuries, up to
999 microcuries N1 N

✽ A9517 Iodine I-131 sodium iodide capsule(s), therapeutic, per millicurie

K
✽ A9520 Technetium Tc-99m tilmanocept, diagnostic, up to 0.5 millicuries
N1 N

✽ A9521 Technetium Tc-99m exametazime, diagnostic, per study dose, up to

25 millicuries N1 N

✽ A9524 Iodine I-131 iodinated serum albumin, diagnostic, per 5 microcuries

N1 N

✽ A9526 Nitrogen N-13 ammonia, diagnostic, per study dose, up to 40

millicuries N1 N

✽ A9527 Iodine I-125, sodium iodide solution, therapeutic, per millicurie

H2 U

✽ A9528 Iodine I-131 sodium iodide capsule(s), diagnostic, per millicurie

N1 N

✽ A9529 Iodine I-131 sodium iodide solution, diagnostic, per millicurie

N1 N
✽ A9530 Iodine I-131 sodium iodide solution, therapeutic, per millicurie
K
✽ A9531 Iodine I-131 sodium iodide, diagnostic, per microcurie (up to 100
microcuries) N1 N

✽ A9532 Iodine I-125 serum albumin, diagnostic, per 5 microcuries

N1 N
✽ A9536 Technetium Tc-99m depreotide, diagnostic, per study dose, up to 35
millicuries N1 N

✽ A9537 Technetium Tc-99m mebrofenin, diagnostic, per study dose, up to

15 millicuries N1 N

✽ A9538 Technetium Tc-99m pyrophosphate, diagnostic, per study dose, up

to 25 millicuries N1 N

✽ A9539 Technetium Tc-99m pentetate, diagnostic, per study dose, up to 25

millicuries N1 N

✽ A9540 Technetium Tc-99m macroaggregated albumin, diagnostic, per

study dose, up to 10 millicuries N1 N

✽ A9541 Technetium Tc-99m sulfur colloid, diagnostic, per study dose, up to

20 millicuries N1 N

✽ A9542 Indium In-111 ibritumomab tiuxetan, diagnostic, per study dose, up

to 5 millicuries N1 N

Specifically for diagnostic use.

✽ A9543 Yttrium Y-90 ibritumomab tiuxetan, therapeutic, per treatment dose,
up to 40 millicuries K

Specifically for therapeutic use.

✽ A9546 Cobalt Co-57/58, cyanocobalamin, diagnostic, per study dose, up to
1 microcurie N1 N

✽ A9547 Indium In-111 oxyquinoline, diagnostic, per 0.5 millicurie

N1 N
✽ A9548 Indium In-111 pentetate, diagnostic, per 0.5 millicurie
N1 N
✽ A9550 Technetium Tc-99m sodium gluceptate, diagnostic, per study dose,
up to 25 millicuries N1 N

✽ A9551 Technetium Tc-99m succimer, diagnostic, per study dose, up to 10

millicuries N1 N

✽ A9552 Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45

millicuries N1 N
Coding Clinic: 2008, Q3, P7
✽ A9553 Chromium Cr-51 sodium chromate, diagnostic, per study dose, up to
250 microcuries N1 N

✽ A9554 Iodine I-125 sodium Iothalamate, diagnostic, per study dose, up to

10 microcuries N1 N

✽ A9555 Rubidium Rb-82, diagnostic, per study dose, up to 60 millicuries

N1 N

✽ A9556 Gallium Ga-67 citrate, diagnostic, per millicurie N1 N

✽ A9557 Technetium Tc-99m bicisate, diagnostic, per study dose, up to 25

millicuries N1 N

✽ A9558 Xenon Xe-133 gas, diagnostic, per 10 millicuries N1 N

✽ A9559 Cobalt Co-57 cyanocobalamin, oral, diagnostic, per study dose, up

to 1 microcurie N1 N

✽ A9560 Technetium Tc-99m labeled red blood cells, diagnostic, per study
dose, up to 30 millicuries N1 N
Coding Clinic: 2008, Q3, P7
✽ A9561 Technetium Tc-99m oxidronate, diagnostic, per study dose, up to 30
millicuries N1 N

✽ A9562 Technetium Tc-99m mertiatide, diagnostic, per study dose, up to 15

millicuries N1 N

✽ A9563 Sodium phosphate P-32, therapeutic, per millicurie K

✽ A9564 Chromic phosphate P-32 suspension, therapeutic, per millicurie

E1

✽ A9566 Technetium Tc-99m fanolesomab, diagnostic, per study dose, up to

25 millicuries N1 N

✽ A9567 Technetium Tc-99m pentetate, diagnostic, aerosol, per study dose,

 up to 75 millicuries N1 N

✽ A9568 Technetium TC-99m arcitumomab, diagnostic, per study dose, up to

45 millicuries N1 N

✽ A9569 Technetium Tc-99m exametazime labeled autologous white blood

cells, diagnostic, per study dose N1 N

✽ A9570 Indium In-111 labeled autologous white blood cells, diagnostic, per
study dose N1 N

✽ A9571 Indium In-111 labeled autologous platelets, diagnostic, per study

dose N1 N

✽ A9572 Indium In-111 pentetreotide, diagnostic, per study dose, up to 6

millicuries N1 N

✽ A9575 Injection, gadoterate meglumine, 0.1 ml N1 N

Other: Clariscan, Gadoterate Meglumine

✽ A9576 Injection, gadoteridol, (ProHance Multipack), per ml
N1 N
✽ A9577 Injection, gadobenate dimeglumine (MultiHance), per ml
N1 N
✽ A9578 Injection, gadobenate dimeglumine (MultiHance Multipack), per ml
N1 N

✽ A9579 Injection, gadolinium-based magnetic resonance contrast agent, not

otherwise specified (NOS), per ml N1 N

Other: Magnevist, Prohance

✽ A9580 Sodium fluoride F-18, diagnostic, per study dose, up to 30
millicuries N1 N

✽ A9581 Injection, gadoxetate disodium, 1 ml N1 N

Local Medicare contractors may require the use of modifier JW to

identify unused product from single-dose vials that are appropriately
discarded.
Other: Eovist
✽ A9582 Iodine I-123 iobenguane, diagnostic, per study dose, up to 15
millicuries N1 N

Molecular imaging agent that assists in the identification of rare

neuroendocrine tumors.
✽ A9583 Injection, gadofosveset trisodium, 1 ml N1 N

✽ A9584 Iodine 1-123 ioflupane, diagnostic, per study dose, up to 5

millicuries N1 N
Coding Clinic: 2012, Q1, P9
✽ A9585 Injection, gadobutrol, 0.1 ml N1 N
 Other: Gadavist
Coding Clinic: 2012, Q1, P8
❂ A9586 Florbetapir F18, diagnostic, per study dose, up to 10 millicuries
N1 N

✽ A9587 Gallium Ga-68, dotatate, diagnostic, 0.1 millicurie K2 G

Coding Clinic: 2017, Q1, P9
✽ A9589 Instillation, hexaminolevulinate hydrochloride, 100 mg N1 N

✽ A9588 Fluciclovine F-18, diagnostic, 1 millicurie K2 G

Coding Clinic: 2017, Q1, P9
✽ A9590 Iodine I-131, iobenguane, 1 millicurie N

✽ A9591 Fluoroestradiol F 18, diagnostic, 1 millicurie K2 G

✽ A9592 Copper cu-64, dotatate, diagnostic, 1 millicurie K2 G

✽ A9593 Gallium ga-68 psma-11, diagnostic, (ucsf), 1 millicurie K2 G

✽ A9594 Gallium ga-68 psma-11, diagnostic, (ucla), 1 millicurie K2 G

✽ A9595 Piflufolastat f-18, diagnostic, 1 millicurie K2 G

▶ A9596 Gallium GA-68 gozetotide, diagnostic, (illuccix), 1 millicurie

✽ A9597 Positron emission tomography radiopharmaceutical, diagnostic, for
tumor identification, not otherwise classified N1 N
Coding Clinic: 2017, Q1, P8-9
✽ A9598 Positron emission tomography radiopharmaceutical, diagnostic, for
non-tumor identification, not otherwise classified N1 N
Coding Clinic: 2017, Q1, P8-9
✽ A9600 Strontium Sr-89 chloride, therapeutic, per millicurie K

▶ A9601 Flortaucipir F 18 injection, diagnostic, 1 millicurie K5 K

▶ A9602 Fluorodopa F-18, diagnostic, per millicurie K2 K

✽ A9604 Samarium SM-153 lexidronam, therapeutic, per treatment dose, up

to 150 millicuries K

✽ A9606 Radium Ra-223 dichloride, therapeutic, per microcurie K

▶ A9607 Lutetium LU 177 vipivotide tetraxetan, therapeutic, 1 millicurie K

❂ A9698 Non-radioactive contrast imaging material, not otherwise classified,

per study N1 N

IOM: 100-04, 12, 70; 100-04, 13, 20

Coding Clinic: 2017, Q1, P8
✽ A9699 Radiopharmaceutical, therapeutic, not otherwise classified N
 ❂ A9700 Supply of injectable contrast material for use in echocardiography,
per study N1 N

IOM: 100-04, 12, 30.4

Coding Clinic: 2017, Q1, P8
▶ A9800 Gallium GA-68 gozetotide, diagnostic, (locametz), 1 millicurie
K2 K

Miscellaneous Service Component

✽ A9900 Miscellaneous DME supply, accessory, and/or service component of
another HCPCS code Y

On DMEPOS fee schedule as a payable replacement for

miscellaneous implanted or non-implanted items.
✽ A9901 DME delivery, set up, and/or dispensing service component of
another HCPCS code A

✽ A9999 Miscellaneous DME supply or accessory, not otherwise specified

Y
On DMEPOS fee schedule as a payable replacement for
miscellaneous implanted or non-implanted items.

ENTERAL AND PARENTERAL THERAPY (B4000-B9999)

Enteral Feeding Supplies
❂ B4034 Enteral feeding supply kit; syringe fed, per day, includes but not
limited to feeding/flushing syringe, administration set tubing,
dressings, tape Y

Dressings used with gastrostomy tubes for enteral nutrition (covered

under the prosthetic device benefit) are included in the payment.
IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2
PEN: On Fee Schedule
❂ B4035 Enteral feeding supply kit; pump fed, per day, includes but not
limited to feeding/flushing syringe, administration set tubing,
dressings, tape Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4036 Enteral feeding supply kit; gravity fed, per day, includes but not
limited to feeding/flushing syringe, administration set tubing,
dressings, tape Y
 IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2
PEN: On Fee Schedule
❂ B4081 Nasogastric tubing with stylet Y

More than 3 nasogastric tubes (B4081-B4083), or 1

gastrostomy/jejunostomy tube (B4087-B4088) every three months is
rarely medically necessary.
IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2
PEN: On Fee Schedule
❂ B4082 Nasogastric tubing without stylet Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4083 Stomach tube - Levine type Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
✽ B4087 Gastrostomy/jejunostomy tube, standard, any material, any type,
each A

PEN: On Fee Schedule

✽ B4088 Gastrostomy/jejunostomy tube, lowprofile, any material, any type,
each A

PEN: On Fee Schedule

Enteral Formulas and Additives

B4100 Food thickener, administered orally, per ounce E1

❂ B4102 Enteral formula, for adults, used to replace fluids and electrolytes
(e.g., clear liquids), 500 ml = 1 unit Y

IOM: 100-03, 3, 180.2

❂ B4103 Enteral formula, for pediatrics, used to replace fluids and
electrolytes (e.g., clear liquids), 500 ml = 1 unit Y

IOM: 100-03, 3, 180.2

❂ B4104 Additive for enteral formula (e.g., fiber) E1

IOM: 100-03, 3, 180.2

❂ B4105 In-line cartridge containing digestive enzyme(s) for enteral feeding,
each Y

Cross Reference Q9994

❂ B4149 Enteral formula, manufactured blenderized natural foods with intact
 nutrients, includes proteins, fats, carbohydrates, vitamins and
minerals, may include fiber, administered through an enteral feeding
tube, 100 calories = 1 unit Y

Produced to meet unique nutrient needs for specific disease

conditions; medical record must document specific condition and
need for special nutrient.
IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2
PEN: On Fee Schedule
❂ B4150 Enteral formulae, nutritionally complete with intact nutrients,
includes proteins, fats, carbohydrates, vitamins, and minerals, may
include fiber, administered through an enteral feeding tube, 100
calories = 1 unit Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4152 Enteral formula, nutritionally complete, calorically dense (equal to
or greater than 1.5 kcal/ml) with intact nutrients, includes proteins,
fats, carbohydrates, vitamins and minerals, may include fiber,
administered through an enteral feeding tube, 100 calories = 1 unit
Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4153 Enteral formula, nutritionally complete, hydrolyzed proteins (amino
acids and peptide chain), includes fats, carbohydrates, vitamins and
minerals, may include fiber, administered through an enteral feeding
tube, 100 calories = 1 unit Y

If 2 enteral nutrition products described by same HCPCS code and

provided at same time billed on single claim line with units of
service reflecting total calories of both nutrients
IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2
PEN: On Fee Schedule
❂ B4154 Enteral formula, nutritionally complete, for special metabolic needs,
excludes inherited disease of metabolism, includes altered
composition of proteins, fats, carbohydrates, vitamins and/or
minerals, may include fiber, administered through an enteral feeding
tube, 100 calories = 1 unit Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4155 Enteral formula, nutritionally incomplete/modular nutrients,
 includes specific nutrients, carbohydrates (e.g., glucose polymers),
proteins/amino acids (e.g., glutamine, arginine), fat (e.g., medium
chain triglycerides) or combination, administered through an enteral
feeding tube, 100 calories = 1 unit Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4157 Enteral formula, nutritionally complete, for special metabolic needs
for inherited disease of metabolism, includes proteins, fats,
carbohydrates, vitamins and minerals, may include fiber,
administered through an enteral feeding tube, 100 calories = 1 unit
Y

IOM: 100-03, 3, 180.2

❂ B4158 Enteral formula, for pediatrics, nutritionally complete with intact
nutrients, includes proteins, fats, carbohydrates, vitamins and
minerals, may include fiber and/or iron, administered through an
enteral feeding tube, 100 calories = 1 unit Y

IOM: 100-03, 3, 180.2

❂ B4159 Enteral formula, for pediatrics, nutritionally complete soy based
with intact nutrients, includes proteins, fats, carbohydrates, vitamins
and minerals, may include fiber and/or iron, administered through
an enteral feeding tube, 100 calories = 1 unit Y

IOM: 100-03, 3, 180.2

❂ B4160 Enteral formula, for pediatrics, nutritionally complete calorically
dense (equal to or greater than 0.7 kcal/ml) with intact nutrients,
includes proteins, fats, carbohydrates, vitamins and minerals, may
include fiber, administered through an enteral feeding tube, 100
calories = 1 unit Y

IOM: 100-03, 3, 180.2

❂ B4161 Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide
chain proteins, includes fats, carbohydrates, vitamins and minerals,
may include fiber, administered through an enteral feeding tube, 100
calories = 1 unit Y

IOM: 100-03, 3, 180.2

❂ B4162 Enteral formula, for pediatrics, special metabolic needs for inherited
disease of metabolism, includes proteins, fats, carbohydrates,
vitamins and minerals, may include fiber, administered through an
enteral feeding tube, 100 calories = 1 unit Y

IOM: 100-03, 3, 180.2

Figure 8 Total Parenteral Nutrition (TPN) involves percutaneous placement of central
venous catheter into vena cava or right atrium.

Parenteral Nutritional Solutions and Supplies

❂ B4164 Parenteral nutrition solution: carbohydrates (dextrose), 50% or less
(500 ml = 1 unit) - home mix Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4168 Parenteral nutrition solution; amino acid, 3.5%, (500 ml = 1 unit) -
home mix Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4172 Parenteral nutrition solution; amino acid, 5.5% through 7%, (500 ml
= 1 unit) - home mix Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

❂ B4176 Parenteral nutrition solution; amino acid, 7% through 8.5%, (500 ml
= 1 unit) - home mix Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4178 Parenteral nutrition solution: amino acid, greater than 8.5% (500 ml
= 1 unit) - home mix Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

 PEN: On Fee Schedule
❂ B4180 Parenteral nutrition solution; carbohydrates (dextrose), greater than
50% (500 ml = 1 unit) - home mix Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4185 Parenteral nutrition solution, not otherwise specified, 10 grams
lipids B

PEN: On Fee Schedule

❂ B4187 Omegaven, 10 grams lipids Y

❂ B4189 Parenteral nutrition solution; compounded amino acid and

carbohydrates with electrolytes, trace elements, and vitamins,
including preparation, any strength, 10 to 51 grams of protein -
premix Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4193 Parenteral nutrition solution; compounded amino acid and
carbohydrates with electrolytes, trace elements, and vitamins,
including preparation, any strength, 52 to 73 grams of protein -
premix Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4197 Parenteral nutrition solution; compounded amino acid and
carbohydrates with electrolytes, trace elements and vitamins,
including preparation, any strength, 74 to 100 grams of protein -
premix Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4199 Parenteral nutrition solution; compounded amino acid and
carbohydrates with electrolytes, trace elements and vitamins,
including preparation, any strength, over 100 grams of protein -
premix Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4216 Parenteral nutrition; additives (vitamins, trace elements, heparin,
electrolytes) home mix per day Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
 ❂ B4220 Parenteral nutrition supply kit; premix, per day Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4222 Parenteral nutrition supply kit; home mix, per day Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4224 Parenteral nutrition administration kit, per day Y

Dressings used with parenteral nutrition (covered under the

prosthetic device benefit) are included in the payment.
(https://www.cms.gov/medicare-coverage-database/search.aspx)
IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2
PEN: On Fee Schedule
❂ B5000 Parenteral nutrition solution compounded amino acid and
carbohydrates with electrolytes, trace elements, and vitamins,
including preparation, any strength, renal - Aminosyn-RF,
NephrAmine, RenAmine - premix Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B5100 Parenteral nutrition solution compounded amino acid and
carbohydrates with electrolytes, trace elements, and vitamins,
including preparation, any strength, hepatic, HepatAmine - premix
Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B5200 Parenteral nutrition solution compounded amino acid and
carbohydrates with electrolytes, trace elements, and vitamins,
including preparation, any strength, stress-branch chain amino
acids-FreAmine-HBC - premix Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

Enteral and Parenteral Pumps

❂ B9002 Enteral nutrition infusion pump, any type Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B9004 Parenteral nutrition infusion pump, portable Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

 PEN: On Fee Schedule
❂ B9006 Parenteral nutrition infusion pump, stationary Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B9998 NOC for enteral supplies Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

❂ B9999 NOC for parenteral supplies Y

Determine if an alternative HCPCS Level II or a CPT code better

describes the service being reported. This code should be reported
only if a more specific code is unavailable.
IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

CMS HOSPITAL OUTPATIENT PAYMENT SYSTEM

(C1000-C9999)
NOTE: C-codes are used on Medicare Ambulatory Surgical Center (ASC) and
Hospital Outpatient Prospective Payment System (OPPS) claims, but may also
be recognized on claims from other providers or by other payment systems. As
of 10/01/2006, the following non-OPPS providers have been able to bill
Medicare using the C-codes, or an appropriate CPT code on Types of Bill
(TOBs) 12X, 13X, or 85X:
• Critical Access Hospitals (CAHs);
• Indian Health Service Hospitals (IHS);
• Hospitals located in American Samoa, Guam, Saipan or the Virgin Islands; and
• Maryland waiver hospitals.
The billing of C-codes by Method I and Method II Critical Access Hospitals
(CAHs) is limited to the billing for facility (technical) services. The C-codes
shall not be billed by Method II CAHs for professional services with revenue
codes (RCs) 96X, 97X, or 98X.
C codes are updated quarterly by the Centers for Medicare and Medicaid
Services (CMS).

Devices and Supplies

❂ C1052 Hemostatic agent, gastrointestinal, topical J7 H
 ❂ C1062 Intravertebral body fracture augmentation with implant (e.g., metal,
polymer) J7 H

❂ C1713 Anchor/Screw for opposing bone-to-bone or soft tissue-to-bone

(implantable) N1 N

Medicare Statute 1833(t)

Coding Clinic: 2022, Q3, P9; 2021, Q1, P9-10; 2020, Q4, P7-8; 2018, Q2, P5; Q1, P4;
2016, Q3, P16; 2015, Q3, P2; 2010, Q2, P3
❂ C1714 Catheter, transluminal atherectomy, directional N1 N

Medicare Statute 1833(t)

❂ C1715 Brachytherapy needle N1 N

Medicare Statute 1833(t)

Brachytherapy Sources
❂ C1716 Brachytherapy source, non-stranded, gold-198, per source
H2 U
Medicare Statute 1833(t)

Figure 9 (A) Brachytherapy device, (B) Brachytherapy device inserted.

❂ C1717 Brachytherapy source, non-stranded, high dose rate iridium 192, per
source H2 U

Medicare Statute 1833(t)

❂ C1719 Brachytherapy source, non-stranded, non-high dose rate iridium-
192, per source H2 U

Medicare Statute 1833(t)

Cardioverter-Defibrilators
❂ C1721 Cardioverter-defibrillator, dual chamber (implantable) N1 N

Related CPT codes: 33224, 33240, 33249.

Medicare Statute 1833(t)
 ❂ C1722 Cardioverter-defibrillator, single chamber (implantable)
N1 N
Related CPT codes: 33240, 33249.
Medicare Statute 1833(t)
Coding Clinic: 2017, Q2, P5; 2006, Q2, P9

Catheters
❂ C1724 Catheter, transluminal atherectomy, rotational N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P9
❂ C1725 Catheter, transluminal angioplasty, non-laser (may include guidance,
infusion/perfusion capability) N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P16, P19
❂ C1726 Catheter, balloon dilatation, nonvascular N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P16, P19
❂ C1727 Catheter, balloon tissue dissector, non-vascular (insertable)
N1 N
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P16
❂ C1728 Catheter, brachytherapy seed administration N1 N

Medicare Statute 1833(t)

❂ C1729 Catheter, drainage N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P17
❂ C1730 Catheter, electrophysiology, diagnostic, other than 3D mapping (19
or fewer electrodes) N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P17
❂ C1731 Catheter, electrophysiology, diagnostic, other than 3D mapping (20
or more electrodes) N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P17
❂ C1732 Catheter, electrophysiology, diagnostic/ablation, 3D or vector
mapping N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P15, P17, P19
❂ C1733 Catheter, electrophysiology, diagnostic/ablation, other than 3D or
 vector mapping, other than cool-tip N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P17
❂ C1734 Orthopedic/device/drug matrix for opposing bone-to-bone or soft
tissue-to-bone (implantable) N1

▶ C1747 Endoscope, single-use (i.e. disposable), urinary tract,

imaging/illumination device (insertable) J7 H

❂ C1748 Endoscope, single-use (i.e. disposable), upper gi,

imaging/illumination device (insertable) J7 H

❂ C1749 Endoscope, retrograde imaging/illumination colonoscope device

(implantable) N1 N

Medicare Statute 1833(t)

❂ C1750 Catheter, hemodialysis/peritoneal, long-term N1 N

Medicare Statute 1833(t)

Coding Clinic: 2015, Q4, P6
❂ C1751 Catheter, infusion, inserted peripherally, centrally, or midline (other
than hemodialysis) N1 N

Medicare Statute 1833(t)

❂ C1752 Catheter, hemodialysis/peritoneal, short-term N1 N

Medicare Statute 1833(t)

❂ C1753 Catheter, intravascular ultrasound N1 N

Medicare Statute 1833(t)

❂ C1754 Catheter, intradiscal N1 N

Medicare Statute 1833(t)

❂ C1755 Catheter, instraspinal N1 N

Medicare Statute 1833(t)

❂ C1756 Catheter, pacing, transesophageal N1 N

Medicare Statute 1833(t)

❂ C1757 Catheter, thrombectomy/embolectomy N1 N

Medicare Statute 1833(t)

❂ C1758 Catheter, ureteral N1 N

Medicare Statute 1833(t)

❂ C1759 Catheter, intracardiac echocardiography N1 N

Medicare Statute 1833(t)

Devices
❂ C1760 Closure device, vascular (implantable/insertable) N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P19
❂ C1761 Catheter, transluminal intravascular lithotripsy, coronary J7

❂ C1762 Connective tissue, human (includes fascia lata) N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P9, P16, P19; 2015, Q3, P2; 2003, Q3, P12
❂ C1763 Connective tissue, non-human (includes synthetic) N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P9, P17, P19; 2010, Q4, P3; Q2, P3; 2003, Q3, P12
❂ C1764 Event recorder, cardiac (implantable) N1 N

Medicare Statute 1833(t)

Coding Clinic: 2015, Q2, P8
❂ C1765 Adhesion barrier N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P16
❂ C1766 Introducer/sheath, guiding, intracardiac electrophysiological,
steerable, other than peel-away N1 N

Medicare Statute 1833(t)

❂ C1767 Generator, neurostimulator (implantable), nonrechargeable
N1 N
Related CPT codes: 61885, 61886, 63685, 64590.
Medicare Statute 1833(t)
Coding Clinic: 2021, Q1, P8; 2007, Q1, P8
❂ C1768 Graft, vascular N1 N

Medicare Statute 1833(t)

❂ C1769 Guide wire N1 N

Medicare Statute 1833(t)

Coding Clinic: 2019, Q3, P10; 2016, Q3, P3; 2007, Q2, P7-8
❂ C1770 Imaging coil, magnetic reasonance (insertable) N1 N

Medicare Statute 1833(t)

❂ C1771 Repair device, urinary, incontinence, with sling graft N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P19; 2008, Q3, P7
❂ C1772 Infusion pump, programmable (implantable) N1 N

Medicare Statute 1833(t)

❂ C1773 Retrieval device, insertable (used to retrieve fractured medical
 devices) N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P19
❂ C1776 Joint device (implantable) N1 N

Medicare Statute 1833(t)

Coding Clinic: 2020, Q1, P16; 2018, Q3, P6; 2016, Q3, P3, P18; 2010, Q3, P6; 2008,
Q4, P10
❂ C1777 Lead, cardioverter-defibrillator, endocardial single coil
(implantable) N1 N

Related CPT codes: 33216, 33217, 33249.

Medicare Statute 1833(t)
Coding Clinic: 2017, Q2, P5; 2006, Q2, P9
❂ C1778 Lead, neurostimulator (implantable) N1 N

Related CPT codes: 43647, 63650, 63655, 63663, 63664, 64553,

64555, 64560, 64561, 64565, 64573, 64575, 64577, 64580, 64581.
Medicare Statute 1833(t)
Coding Clinic: 2021, Q1, P8; 2019, Q1, P5; 2007, Q1, P8
❂ C1779 Lead, pacemaker, trasvenous VDD single pass N1 N

Related CPT codes: 33206, 33207, 33208, 33210, 33211, 33214,

33216, 33217, 33249.
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P19
❂ C1780 Lens, intraocular (new technology) N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P18
❂ C1781 Mesh (implantable) N1 N

Medicare Statute 1833(t)

Coding Clinic: 2019, Q1, P5; 2016, Q3, P18-19; 2012, Q2, P3; 2010, Q2, P2-3
❂ C1782 Morcellator N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P18
❂ C1783 Ocular implant, aqueous drainage assist device N1 N

Medicare Statute 1833(t)

Coding Clinic: 2017, Q1, P5
❂ C1784 Ocular device, intraoperative, detached retina N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P18
 ❂ C1785 Pacemaker, dual chamber, rateresponsive (implantable)
N1 N
Related CPT codes: 33206, 33207, 33208, 33213, 33214,
33224.
Medicare Statute 1833(t)

Figure 10 (A) Single pacemaker, (B) Dual pacemaker, (C) Biventricular pacemaker.

❂ C1786 Pacemaker, single chamber, rateresponsive (implantable)

N1 N
Related CPT codes: 33206, 33207, 33212.
Medicare Statute 1833(t)
❂ C1787 Patient programmer, neurostimulator N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P19
❂ C1788 Port, indwelling (implantable) N1 N

Medicare Statute 1833(t)

❂ C1789 Prosthesis, breast (implantable) N1 N

Medicare Statute 1833(t)

❂ C1813 Prosthesis, penile, inflatable ♂ N1 N

Medicare Statute 1833(t)

❂ C1814 Retinal tamponade device, silicone oil N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P19; 2006, Q2, P9
❂ C1815 Prosthesis, urinary sphincter (implantable) N1 N

Medicare Statute 1833(t)

❂ C1816 Receiver and/or transmitter, neurostimulator (implantable)
N1 N
Medicare Statute 1833(t)
❂ C1817 Septal defect implant system, intracardiac N1 N

Medicare Statute 1833(t)

 Coding Clinic: 2016, Q3, P19
❂ C1818 Integrated keratoprosthesic N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P18
❂ C1819 Surgical tissue localization and excision device (implantable)
N1 N
Medicare Statute 1833(t)
❂ C1820 Generator, neurostimulator (implantable), with rechargeable battery
and charging system N1 N

Related CPT codes: 61885, 61886, 63685, 64590.

Medicare Statute 1833(t)
Coding Clinic: 2016, Q2, P7
❂ C1821 Interspinous process distraction device (implantable) N1 N

Medicare Statute 1833(t)

❂ C1822 Generator, neurostimulator (implantable), high frequency, with
rechargeable battery and charging system N1 N

Medicare Statute 1833(T)

Coding Clinic: 2016, Q2, P7
❂ C1823 Generator, neurostimulator (implantable), non-rechargeable, with
transvenous sensing and stimulation leads H

Medicare Statute 1833(t)

❂ C1824 Generator, cardiac contractility modulation (implantable) N1

❂ C1825 Generator, neurostimulator (implantable), non-rechargeable with

carotid sinus baroreceptor stimulation lead(s) J7 H

▶ ❂ C1826 Generator, neurostimulator (implantable), includes closed feedback

loop leads and all implantable components, with rechargeable
battery and charging system J7 H

▶ ❂ C1827 Generator, neurostimulator (implantable), non-rechargeable, with

implantable stimulation lead and external paired stimulation
controller J7 H

❂ C1830 Powered bone marrow biopsy needle N1 N

Medicare Statute 1833(t)

❂ C1831 Interbody cage, anterior, lateral or posterior, personalized
(implantable) J7 H

❂ C1832 Autograft suspension, including cell processing and application, and

all system components J7 H
 ❂ C1833 Monitor, cardiac, including intracardiac lead and all system
components (implantable) J7 H

▶ ❂ C1834 Pressure sensor system, includes all components (e.g., introducer,

sensor), intramuscular (implantable), excludes mobile (wireless)
software application J7 H

❂ C1839 Iris prosthesis N1

❂ C1840 Lens, intraocular (telescopic) N1 N

Medicare Statute 1833(t)

Coding Clinic: 2012, Q3, P10
C1841 Retinal prosthesis, includes all internal and external ✖
components
C1842 Retinal prosthesis, includes all internal and external ✖
components; add-on to C1841
C1849 Skin substitute, synthetic, resorbable, per square centimeter ✖
❂ C1874 Stent, coated/covered, with delivery system N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P16-17, P19
❂ C1875 Stent, coated/covered, without delivery system N1 N

Medicare Statute 1833(t)

Coding Clinic: 2020, Q2, P9; 2016, Q3, P16-17
❂ C1876 Stent, non-coated/non-covered, with delivery system N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P19
❂ C1877 Stent, non-coated/non-covered, without delivery system N1 N

Medicare Statute 1833(t)

❂ C1878 Material for vocal cord medialization, synthetic (implantable)
N1 N
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P18
❂ C1880 Vena cava filter N1 N

Medicare Statute 1833(t)

❂ C1881 Dialysis access system (implantable) N1 N

Medicare Statute 1833(t)

❂ C1882 Cardioverter-defibrillator, other than single or dual chamber
(implantable) N1 N

Related CPT codes: 33224, 33240, 33249.

Medicare Statute 1833(t)
 Coding Clinic: 2016, Q3, P16; 2012, Q2, P9; 2006, Q2, P9
❂ C1883 Adapter/Extension, pacing lead or neurostimulator lead
(implantable) N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P15, P17; 2007, Q1, P8
❂ C1884 Embolization protective system N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P17
❂ C1885 Catheter, transluminal angioplasty, laser N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, p16, Q1, P5
❂ C1886 Catheter, extravascular tissue ablation, any modality (insertable)
N1 N
Medicare Statute 1833(t)
❂ C1887 Catheter, guiding (may include infusion/perfusion capability)
N1 N
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P17
❂ C1888 Catheter, ablation, non-cardiac, endovascular (implantable)
N1 N
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P16
❂ C1889 Implantable/insertable device, not otherwise classified N1 N

Medicare Statute 1833(T)

❂ C1891 Infusion pump, non-programmable, permanent (implantable)
N1 N
Medicare Statute 1833(t)
❂ C1892 Introducer/sheath, guiding, intracardiac electrophysiological, fixed-
curve, peel-away N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P19
❂ C1893 Introducer/sheath, guiding, intracardiac electrophysiological, fixed-
curve, other than peel-away N1 N

Medicare Statute 1833(t)

❂ C1894 Introducer/sheath, other than guiding, other than intracardiac
electrophysiological, non-laser N1 N

Medicare Statute 1833(t)

❂ C1895 Lead, cardioverter-defibrillator, endocardial dual coil (implantable)
N1 N
Related CPT codes: 33216, 33217, 33249.
 Medicare Statute 1833(t)
Coding Clinic: 2006, Q2, P9
❂ C1896 Lead, cardioverter-defibrillator, other than endocardial single or dual
coil (implantable) N1 N

Related CPT codes: 33216, 33217, 33249.

Medicare Statute 1833(t)
❂ C1897 Lead, neurostimulator test kit (implantable) N1 N

Related CPT codes: 43647, 63650, 63655, 63663, 63664, 64553,

64555, 64560, 64561, 64565, 64575, 64577, 64580, 64581.
Medicare Statute 1833(t)
Coding Clinic: 2007, Q1, P8
❂ C1898 Lead, pacemaker, other than transvenous VDD single pass
N1 N
Related CPT codes: 33206, 33207, 33208, 33210, 33211,
33214, 33216, 33217, 33249.
Medicare Statute 1833(t)
Coding Clinic: 2002, Q3, P8
❂ C1899 Lead, pacemaker/cardioverter-defibrillator combination
(implantable) N1 N

Related CPT codes: 33216, 33217, 33249.

Medicare Statute 1833(t)
❂ C1900 Lead, left ventricular coronary venous system N1 N

Related CPT codes: 33224, 33225.

Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P18
❂ C1982 Catheter, pressure-generating, one-way valve, intermittently
occlusive N1

❂ C2596 Probe, image-guided, robotic, waterjet ablation N1 H

❂ C2613 Lung biopsy plug with delivery system N1 H

Medicare Statute 1833(t)

Coding Clinic: 2015, Q2, P11
❂ C2614 Probe, percutaneous lumbar discectomy N1 N

Medicare Statute 1833(t)

❂ C2615 Sealant, pulmonary, liquid N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P18
Brachytherapy Source
❂ C2616 Brachytherapy source, non-stranded, yttrium-90, per source
H2 U
Medicare Statute 1833(t)

Cardiovascular and Genitourinary Devices

❂ C2617 Stent, non-coronary, temporary, without delivery system N1 N

Medicare Statute 1833(t)

Coding Clinic: 2018, Q1, P4; 2016, Q3, P3, P19
❂ C2618 Probe/needle, cryoablation N1 N

Medicare Statute 1833(t)

❂ C2619 Pacemaker, dual chamber, non rateresponsive (implantable)
N1 N
Related CPT codes: 33206, 33207, 33208, 33213, 33214,
33224.
Medicare Statute 1833(t)
❂ C2620 Pacemaker, single chamber, non rateresponsive (implantable)
N1 N
Related CPT codes: 33206, 33207, 33212, 33224.
Medicare Statute 1833(t)
❂ C2621 Pacemaker, other than single or dual chamber (implantable)
N1 N
Related CPT codes: 33206, 33207, 33208, 33212, 33213,
33214, 33224.
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P18; 2002, Q3, P8
❂ C2622 Prosthesis, penile, noninflatable ♂ N1 N

Medicare Statute 1833(t)

❂ C2623 Catheter, transluminal angioplasty, drug-coated, non-laser
N1 N
Medicare Statute 1833(t)
❂ C2624 Implantable wireless pulmonary artery pressure sensor with delivery
catheter, including all system components N1 N

Medicare Statute 1833(t)

Coding Clinic: 2015, Q3, P2
❂ C2625 Stent, non-coronary, temporary, with delivery system N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P19; 2015, Q2, P9
❂ C2626 Infusion pump, non-programmable, temporary (implantable)
N1 N
Medicare Statute 1833(t)
 Coding Clinic: 2016, Q3, P18
❂ C2627 Catheter, suprapubic/cystoscopic N1 N

Medicare Statute 1833(t)

❂ C2628 Catheter, occlusion N1 N

Medicare Statute 1833(t)

❂ C2629 Introducer/Sheath, other than guiding, other than intracardiac
electrophysiological, laser N1 N

Medicare Statute 1833(t)

❂ C2630 Catheter, electrophysiology, diagnostic/ablation, other than 3D or
vector mapping, cool-tip N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P17
❂ C2631 Repair device, urinary, incontinence, without sling graft
N1 N
Medicare Statute 1833(t)

Brachytherapy Sources
❂ C2634 Brachytherapy source, non-stranded, high activity, iodine-125,
greater than 1.01 mci (NIST), per source H2 U

Medicare Statute 1833(t)

❂ C2635 Brachytherapy source, non-stranded, high activity, palladium-103,
greater than 2.2 mci (NIST), per source H2 U

Medicare Statute 1833(t)

❂ C2636 Brachytherapy linear source, non-stranded, palladium-103, per 1
mm H2 U

❂ C2637 Brachytherapy source, non-stranded, Ytterbium-169, per source

B
Medicare Statute 1833(t)
❂ C2638 Brachytherapy source, stranded, iodine-125, per source
H2 U
Medicare Statute 1833(t)(2)
❂ C2639 Brachytherapy source, non-stranded, iodine-125, per source
H2 U
Medicare Statute 1833(t)(2)
❂ C2640 Brachytherapy source, stranded, palladium-103, per source
H2 U
Medicare Statute 1833(t)(2)
❂ C2641 Brachytherapy source, non-stranded, palladium-103, per source
H2 U
Medicare Statute 1833(t)(2)
 ❂ C2642 Brachytherapy source, stranded, cesium-131, per source
H2 U
Medicare Statute 1833(t)(2)
❂ C2643 Brachytherapy source, non-stranded, cesium-131, per source
H2 U
Medicare Statute 1833(t)(2)
❂ C2644 Brachytherapy source, Cesium-131 chloride solution, per millicurie
H2 U

Medicare Statute 1833(t)

❂ C2645 Brachytherapy planar source, palladium-103, per square millimeter
H2 U

Medicare Statute 1833(T)

❂ C2698 Brachytherapy source, stranded, not otherwise specified, per source
H2 U
Medicare Statute 1833(t)(2)
❂ C2699 Brachytherapy source, non-stranded, not otherwise specified, per
source H2 U

Medicare Statute 1833(t)(2)

Skin Substitute Graft Application

❂ C5271 Application of low cost skin substitute graft to trunk, arms, legs,
total wound surface area up to 100 sq cm; first 25 sq cm or less
wound surface area T

Medicare Statute 1833(t)

❂ C5272 Application of low cost skin substitute graft to trunk, arms, legs,
total wound surface area up to 100 sq cm; each additional 25 sq cm
wound surface area, or part thereof (list separately in addition to
code for primary procedure) N

Medicare Statute 1833(t)

❂ C5273 Application of low cost skin substitute graft to trunk, arms, legs,
total wound surface area greater than or equal to 100 sq cm; first
100 sq cm wound surface area, or 1% of body area of infants and
children T

Medicare Statute 1833(t)

❂ C5274 Application of low cost skin substitute graft to trunk, arms, legs,
total wound surface area greater than or equal to 100 sq cm; each
additional 100 sq cm wound surface area, or part thereof, or each
additional 1% of body area of infants and children, or part thereof
(list separately in addition to code for primary procedure)
N
Medicare Statute 1833(t)
❂ C5275 Application of low cost skin substitute graft to face, scalp, eyelids,
mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple
digits, total wound surface area up to 100 sq cm; first 25 sq cm or
less wound surface area T

Medicare Statute 1833(t)

❂ C5276 Application of low cost skin substitute graft to face, scalp, eyelids,
mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple
digits, total wound surface area up to 100 sq cm; each additional 25
sq cm wound surface area, or part thereof (list separately in addition
to code for primary procedure) N

Medicare Statute 1833(t)

❂ C5277 Application of low cost skin substitute graft to face, scalp, eyelids,
mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple
digits, total wound surface area greater than or equal to 100 sq cm;
first 100 sq cm wound surface area, or 1% of body area of infants
and children T

Medicare Statute 1833(t)

❂ C5278 Application of low cost skin substitute graft to face, scalp, eyelids,
mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple
digits, total wound surface area greater than or equal to 100 sq cm;
each additional 100 sq cm wound surface area, or part thereof, or
each additional 1% of body area of infants and children, or part
thereof (list separately in addition to code for primary procedure)
N

Medicare Statute 1833(t)

▶ C7500 Debridement, bone including epidermis, dermis, subcutaneous
tissue, muscle and/or fascia, if performed, first 20 sq cm or less with
manual preparation and insertion of deep (eg, subfacial) drug-
delivery device(s) E1

▶ C7501 Percutaneous breast biopsies using stereotactic guidance, with

placement of breast localization device(s) (eg, clip, metallic pellet),
when performed, and imaging of the biopsy specimen, when
performed, all lesions unilateral and bilateral (for single lesion
biopsy, use appropriate code) E1

▶ C7502 Percutaneous breast biopsies using magnetic resonance guidance,

with placement of breast localization device(s) (eg, clip, metallic
pellet), when performed, and imaging of the biopsy specimen, when
performed, all lesions unilateral or bilateral (for single lesion biopsy,
use appropriate code) E1
▶ C7503 Open biopsy or excision of deep cervical node(s) with intraoperative
identification (eg, mapping) of sentinel lymph node(s) including
injection of non-radioactive dye when performed E1

▶ C7504 Percutaneous vertebroplasties (bone biopsies included when

performed), first cervicothoracic and any additional cervicothoracic
or lumbosacral vertebral bodies, unilateral or bilateral injection,
inclusive of all imaging guidance E1

▶ C7505 Percutaneous vertebroplasties (bone biopsies included when

performed), first lumbosacral and any additional cervicothoracic or
lumbosacral vertebral bodies, unilateral or bilateral injection,
inclusive of all imaging guidance E1

▶ C7506 Arthrodesis, interphalangeal joints, with or without internal fixation

E1
▶ C7507 Percutaneous vertebral augmentations, first thoracic and any
additional thoracic or lumbar vertebral bodies, including cavity
creations (fracture reductions and bone biopsies included when
performed) using mechanical device (eg, kyphoplasty), unilateral or
bilateral cannulations, inclusive of all imaging guidance E1

▶ C7508 Percutaneous vertebral augmentations, first lumbar and any

additional thoracic or lumbar vertebral bodies, including cavity
creations (fracture reductions and bone biopsies included when
performed) using mechanical device (eg, kyphoplasty), unilateral or
bilateral cannulations, inclusive of all imaging guidance E1

▶ C7509 Bronchoscopy, rigid or flexible, diagnostic with cell washing(s)

when performed, with computer-assisted image-guided navigation,
including fluoroscopic guidance when performed E1

▶ C7510 Bronchoscopy, rigid or flexible, with bronchial alveolar lavage(s),

with computer-assisted image-guided navigation, including
fluoroscopic guidance when performed E1

▶ C7511 Bronchoscopy, rigid or flexible, with single or multiple bronchial or

endobronchial biopsy(ies), single or multiple sites, with computer-
assisted image-guided navigation, including fluoroscopic guidance
when performed E1

▶ C7512 Bronchoscopy, rigid or flexible, with single or multiple bronchial or

endobronchial biopsy(ies), single or multiple sites, with
transendoscopic endobronchial ultrasound (EBUS) during
bronchoscopic diagnostic or therapeutic intervention(s) for
peripheral lesion(s), including fluoroscopic guidance when
performed E1
▶ C7513 Dialysis circuit, introduction of needle(s) and/or catheter(s), with
diagnostic angiography of the dialysis circuit, including all direct
puncture(s) and catheter placement(s), injection(s) of contrast, all
necessary imaging from the arterial anastomosis and adjacent artery
through entire venous outflow including the inferior or superior
vena cava, fluoroscopic guidance, with transluminal balloon
angioplasty of central dialysis segment, performed through dialysis
circuit, including all required imaging, radiological supervision and
interpretation, image documentation and report E1

▶ C7514 Dialysis circuit, introduction of needle(s) and/or catheter(s), with

diagnostic angiography of the dialysis circuit, including all direct
puncture(s) and catheter placement(s), injection(s) of contrast, all
necessary imaging from the arterial anastomosis and adjacent artery
through entire venous outflow including the inferior or superior
vena cava, fluoroscopic guidance, with all angioplasty in the central
dialysis segment, and transcatheter placement of intravascular
stent(s), central dialysis segment, performed through dialysis circuit,
including all required imaging, radiological supervision and
interpretation, image documentation and report E1

▶ C7515 Dialysis circuit, introduction of needle(s) and/or catheter(s), with

diagnostic angiography of the dialysis circuit, including all direct
puncture(s) and catheter placement(s), injection(s) of contrast, all
necessary imaging from the arterial anastomosis and adjacent artery
through entire venous outflow including the inferior or superior
vena cava, fluoroscopic guidance, with dialysis circuit permanent
endovascular embolization or occlusion of main circuit or any
accessory veins, including all required imaging, radiological
supervision and interpretation, image documentation and report
E1
▶ C7516 Catheter placement in coronary artery(s) for coronary angiography,
including intraprocedural injection(s) for coronary angiography,
with endoluminal imaging of initial coronary vessel or graft using
intravascular ultrasound (IVUS) or optical coherence tomography
(OCT) during diagnostic evaluation and/or therapeutic intervention
including imaging supervision, interpretation and report E1

▶ C7517 Catheter placement in coronary artery(s) for coronary angiography,

including intraprocedural injection(s) for coronary angiography,
with iliac and/or femoral artery angiography, non-selective, bilateral
or ipsilateral to catheter insertion, performed at the same time as
cardiac catheterization and/or coronary angiography, includes
positioning or placement of the catheter in the distal aorta or
 ipsilateral femoral or iliac artery, injection of dye, production of
permanent images, and radiologic supervision and interpretation
E1
▶ C7518 Catheter placement in coronary artery(ies) for coronary
angiography, including intraprocedural injection(s) for coronary
angiography, imaging supervision and interpretation, with catheter
placement(s) in bypass graft(s) (internal mammary, free arterial,
venous grafts) including intraprocedural injection(s) for bypass graft
angiography with endoluminal imaging of initial coronary vessel or
graft using intravascular ultrasound (IVUS) or optical coherence
tomography (OCT) during diagnostic evaluation and/or therapeutic
intervention including imaging, supervision, interpretation and
report E1

▶ C7519 Catheter placement in coronary artery(ies) for coronary

angiography, including intraprocedural injection(s) for coronary
angiography, imaging supervision and interpretation, with catheter
placement(s) in bypass graft(s) (internal mammary, free arterial,
venous grafts) including intraprocedural injection(s) for bypass graft
angiography with intravascular doppler velocity and/or pressure
derived coronary flow reserve measurement (initial coronary vessel
or graft) during coronary angiography including pharmacologically
induced stress E1

▶ C7520 Catheter placement in coronary artery(ies) for coronary

angiography, including intraprocedural injection(s) for coronary
angiography, imaging supervision and interpretation, with catheter
placement(s) in bypass graft(s) (internal mammary, free arterial,
venous grafts) includes intraprocedural injection(s) for bypass graft
angiography with iliac and/or femoral artery angiography, non-
selective, bilateral or ipsilateral to catheter insertion, performed at
the same time as cardiac catheterization and/or coronary
angiography, includes positioning or placement of the catheter in the
distal aorta or ipsilateral femoral or iliac artery, injection of dye,
production of permanent images, and radiologic supervision and
interpretation E1

▶ C7521 Catheter placement in coronary artery(ies) for coronary

angiography, including intraprocedural injection(s) for coronary
angiography with right heart catheterization with endoluminal
imaging of initial coronary vessel or graft using intravascular
ultrasound (IVUS) or optical coherence tomography (OCT) during
diagnostic evaluation and/or therapeutic intervention including
imaging supervision, interpretation and report E1
▶ C7522 Catheter placement in coronary artery(ies) for coronary
angiography, including intraprocedural injection(s) for coronary
angiography, imaging supervision and interpretation with right heart
catheterization, with intravascular doppler velocity and/or pressure
derived coronary flow reserve measurement (initial coronary vessel
or graft) during coronary angiography including pharmacologically
induced stress E1

▶ C7523 Catheter placement in coronary artery(ies) for coronary

angiography, including intraprocedural injection(s) for coronary
angiography, imaging supervision and interpretation, with left heart
catheterization including intraprocedural injection(s) for left
ventriculography, when performed, with endoluminal imaging of
initial coronary vessel or graft using intravascular ultrasound
(IVUS) or optical coherence tomography (OCT) during diagnostic
evaluation and/or therapeutic intervention including imaging
supervision, interpretation and report E1

▶ C7524 Catheter placement in coronary artery(ies) for coronary

angiography, including intraprocedural injection(s) for coronary
angiography, imaging supervision and interpretation, with left heart
catheterization including intraprocedural injection(s) for left
ventriculography, when performed, with intravascular doppler
velocity and/or pressure derived coronary flow reserve measurement
(initial coronary vessel or graft) during coronary angiography
including pharmacologically induced stress E1

▶ C7525 Catheter placement in coronary artery(ies) for coronary

angiography, including intraprocedural injection(s) for coronary
angiography, imaging supervision and interpretation, with left heart
catheterization including intraprocedural injection(s) for left
ventriculography, when performed, catheter placement(s) in bypass
graft(s) (internal mammary, free arterial, venous grafts) with bypass
graft angiography with endoluminal imaging of initial coronary
vessel or graft using intravascular ultrasound (IVUS) or optical
coherence tomography (OCT) during diagnostic evaluation and/or
therapeutic intervention including imaging supervision,
interpretation and report E1

▶ C7526 Catheter placement in coronary artery(ies) for coronary

angiography, including intraprocedural injection(s) for coronary
angiography, imaging supervision and interpretation, with left heart
catheterization including intraprocedural injection(s) for left
ventriculography, when performed, catheter placement(s) in bypass
 graft(s) (internal mammary, free arterial, venous grafts) with bypass
graft angiography with intravascular doppler velocity and/or
pressure derived coronary flow reserve measurement (initial
coronary vessel or graft) during coronary angiography including
pharmacologically induced stress E1

▶ C7527 Catheter placement in coronary artery(ies) for coronary

angiography, including intraprocedural injection(s) for coronary
angiography, imaging supervision and interpretation, with right and
left heart catheterization including intraprocedural injection(s) for
left ventriculography, when performed, with endoluminal imaging
of initial coronary vessel or graft using intravascular ultrasound
(IVUS) or optical coherence tomography (OCT) during diagnostic
evaluation and/or therapeutic intervention including imaging
supervision, interpretation and report E1

▶ C7528 Catheter placement in coronary artery(ies) for coronary

angiography, including intraprocedural injection(s) for coronary
angiography, imaging supervision and interpretation, with right and
left heart catheterization including intraprocedural injection(s) for
left ventriculography, when performed, with intravascular doppler
velocity and/or pressure derived coronary flow reserve measurement
(initial coronary vessel or graft) during coronary angiography
including pharmacologically induced stress E1

▶ C7529 Catheter placement in coronary artery(ies) for coronary

angiography, including intraprocedural injection(s) for coronary
angiography, imaging supervision and interpretation, with right and
left heart catheterization including intraprocedural injection(s) for
left ventriculography, when performed, catheter placement(s) in
bypass graft(s) (internal mammary, free arterial, venous grafts) with
bypass graft angiography with intravascular doppler velocity and/or
pressure derived coronary flow reserve measurement (initial
coronary vessel or graft) during coronary angiography including
pharmacologically induced stress E1

▶ C7530 Dialysis circuit, introduction of needle(s) and/or catheter(s), with

diagnostic angiography of the dialysis circuit, including all direct
puncture(s) and catheter placement(s), injection(s) of contrast, all
necessary imaging from the arterial anastomosis and adjacent artery
through entire venous outflow including the inferior or superior
vena cava, fluoroscopic guidance, with transluminal balloon
angioplasty, peripheral dialysis segment, including all imaging and
radiological supervision and interpretation necessary to perform the
 angioplasty and all angioplasty in the central dialysis segment, with
transcatheter placement of intravascular stent(s), central dialysis
segment, performed through dialysis circuit, including all imaging,
radiological supervision and interpretation, documentation and
report E1

▶ C7531 Revascularization, endovascular, open or percutaneous, femoral,

popliteal artery(ies), unilateral, with transluminal angioplasty with
intravascular ultrasound (initial noncoronary vessel) during
diagnostic evaluation and/or therapeutic intervention, including
radiological supervision and interpretation E1

▶ C7532 Transluminal balloon angioplasty (except lower extremity

artery(ies) for occlusive disease, intracranial, coronary, pulmonary,
or dialysis circuit), initial artery, open or percutaneous, including all
imaging and radiological supervision and interpretation necessary to
perform the angioplasty within the same artery, with intravascular
ultrasound (initial noncoronary vessel) during diagnostic evaluation
and/or therapeutic intervention, including radiological supervision
and interpretation E1

▶ C7533 Percutaneous transluminal coronary angioplasty, single major

coronary artery or branch with transcatheter placement of radiation
delivery device for subsequent coronary intravascular brachytherapy
E1
▶ C7534 Revascularization, endovascular, open or percutaneous, femoral,
popliteal artery(ies), unilateral, with atherectomy, includes
angioplasty within the same vessel, when performed with
intravascular ultrasound (initial noncoronary vessel) during
diagnostic evaluation and/or therapeutic intervention, including
radiological supervision and interpretation E1

▶ C7535 Revascularization, endovascular, open or percutaneous, femoral,

popliteal artery(ies), unilateral, with transluminal stent placement(s),
includes angioplasty within the same vessel, when performed, with
intravascular ultrasound (initial noncoronary vessel) during
diagnostic evaluation and/or therapeutic intervention, including
radiological supervision and interpretation E1

▶ C7537 Insertion of new or replacement of permanent pacemaker with atrial

transvenous electrode(s), with insertion of pacing electrode, cardiac
venous system, for left ventricular pacing, at time of insertion of
implantable debribrillator or pacemake pulse generator (eg, for
upgrade to dual chamber system) E1

▶ C7538 Insertion of new or replacement of permanent pacemaker with

 ventricular transvenous electrode(s), with insertion of pacing
electrode, cardiac venous system, for left ventricular pacing, at time
of insertion of implantable defribrillator or pacemaker pulse
generator (eg, for upgrade to dual chamber system) E1

▶ C7539 Insertion of new or replacement of permanent pacemaker with atrial

and ventricular transvenous electrode(s), with insertion of pacing
electrode, cardiac venous system, for left ventricular pacing, at time
of insertion of implantable defibrillator or pacemaker pulse
generator (eg, for upgrade to dual chamber system) E1

▶ C7540 Removal of permanent pacemaker pulse generator with replacement

of pacemaker pulse generator, dual lead system, with insertion of
pacing electrode, cardiac venous system, for left ventricular pacing,
at time of insertion of implantable defibrillator or pacemaker pulse
generator (eg, for upgrade to dual chamber system) E1

▶ C7541 Diagnostic endoscopic retrograde cholangiopancreatography

(ERCP), including collection of specimen(s) by brushing or
washing, when performed, with endoscopic cannulation of papilla
with direct visualization of pancreatic/common bile ducts(s) E1

▶ C7542 Endoscopic retrograde cholangiopancreatography (ercp) with

biopsy, single or multiple, with endoscopic cannulation of papilla
with direct visualization of pancreatic/common bile ducts(s) E1

▶ C7543 Endoscopic retrograde cholangiopancreatography (ERCP) with

sphincterotomy/papillotomy, with endoscopic cannulation of papilla
with direct visualization of pancreatic/common bile ducts(s) E1

▶ C7544 Endoscopic retrograde cholangiopancreatography (ERCP) with

removal of calculi/debris from biliary/pancreatic duct(s), with
endoscopic cannulation of papilla with direct visualization of
pancreatic/common bile ducts(s) E1

▶ C7545 Percutaneous exchange of biliary drainage catheter (eg, external,

internal-external, or conversion of internal-external to external
only), with removal of calculi/debris from biliary duct(s) and/or
gallbladder, including destruction of calculi by any method (eg,
mechanical, electrohydraulic, lithotripsy) when performed,
including diagnostic cholangiography(ies) when performed, imaging
guidance (eg, fluoroscopy), and all associated radiological
supervision and interpretation E1

▶ C7546 Removal and replacement of externally accessible nephroureteral

catheter (eg, external/internal stent) requiring fluoroscopic guidance,
with ureteral stricture balloon dilation, including imaging guidance
and all associated radiological supervision and interpretation E1
▶ C7547 Convert nephrostomy catheter to nephroureteral catheter,
percutaneous via pre-existing nephrostomy tract, with ureteral
stricture balloon dialation, including diagnostic nephrostogram
and/or ureterogram when performed, imaging guidance (eg,
ultrasound and/or fluoroscopy) and all associated radiological
supervision and interpretation E1

▶ C7548 Exchange nephrostomy catheter, percutaneous, with ureteral

stricture balloon dilation, including diagnostic nephrostogram
and/or ureterogram when performed, imaging guidance (eg,
ultrasound and/or fluoroscopy) and all associated radiological
supervision and interpretation E1

▶ C7549 Change of ureterostomy tube or externally accessible ureteral stent

via ileal conduit with ureteral stricture balloon dilation, including
imaging guidance (eg, ultrasound and/or fluoroscopy) and all
associated radiological supervision and interpretation E1

▶ C7550 Cystourethroscopy, with biopsy(ies) with adjuctive blue light

cystoscopy with fluorescent imaging agent E1

▶ C7551 Excision of major peripheral nerve neuroma, except sciatic, with

implantation of nerve end into bone or muscle E1

▶ C7552 Catheter placement in coronary artery(s) for coronary angiography,

including intraprocedural injection(s) for coronary angiography,
imaging supervision and interpretation; with catheter placement(s)
in bypass graft(s) (internal mammary, free arterial, venous grafts)
including intraprocedural injection(s) for bypass graft angiography
and right heart catheterization with intravascular doppler velocity
and/or pressure derived coronary flow reserve measurement
(coronary vessel or graft) during coronary angiography including
pharmacologically induced stress, initial vessel E1

▶ C7553 Catheter placement in coronary artery(s) for coronary angiography,

including intraprocedural injection(s) for coronary angiography,
imaging supervision and interpretation; with right and left heart
catheterization including intraprocedural injection(s) for left
ventriculography, when performed, catheter placement(s) in bypass
graft(s) (internal mammary, free arterial, venous grafts) with bypass
graft angiography with pharmacologic agent administration (eg,
inhaled nitric oxide, intravenous infusion of nitroprusside,
dobutamine, milrinone, or other agent) including assessing
hemodynamic measurements before, during, after and repeat
pharmacologic agent administration, when performed E1

Cystourethroscopy with adjunctive blue light cystoscopy with

▶ C7554 fluorescent imaging agent E1

▶ C7555 Thyroidectomy, total or complete with parathyroid

autotransplantation E1

▶ C7900 Service for diagnosis, evaluation, or treatment of a mental health or

substance use disorder, initial 15-29 minutes, provided remotely by
hospital staff who are licensed to provide mental health services
under applicable state law(s), when the patient is in their home, and
there is no associated professional service S

▶ C7901 Service for diagnosis, evaluation, or treatment of a mental health or

substance use disorder, initial 30-60 minutes, provided remotely by
hospital staff who are licensed to provided mental health services
under applicable state law(s), when the patient is in their home, and
there is no associated professional service S

▶ C7902 Service for diagnosis, evaluation, or treatment of a mental health or

substance use disorder, each additional 15 minutes, provided
remotely by hospital staff who are licensed to provide mental health
services under applicable state law(s), when the patient is in their
home, and there is no associated professional service (list separately
in addition to code for primary service) N
Magnetic Resonance Angiography: Trunk and Lower Extremities
❂ C8900 Magnetic resonance angiography with contrast, abdomen
Z2 Q3
Medicare Statute 1833(t)(2)
❂ C8901 Magnetic resonance angiography without contrast, abdomen
Z2 Q3
Medicare Statute 1833(t)(2)
❂ C8902 Magnetic resonance angiography without contrast followed by with
contrast, abdomen Z2 Q3

Medicare Statute 1833(t)(2)

❂ C8903 Magnetic resonance imaging with contrast, breast; unilateral
Z2 Q3
Medicare Statute 1833(t)(2)
❂ C8905 Magnetic resonance imaging without contrast followed by with
contrast, breast; unilateral Z2 Q3

Medicare Statute 1833(t)(2)

❂ C8906 Magnetic resonance imaging with contrast, breast; bilateral
Z2 Q3
Medicare Statute 1833(t)(2)
❂ C8908 Magnetic resonance imaging without contrast followed by with
contrast, breast; bilateral Z2 Q3

Medicare Statute 1833(t)(2)

❂ C8909 Magnetic resonance angiography with contrast, chest (excluding
myocardium) Z2 Q3

Medicare Statute 1833(t)(2)

❂ C8910 Magnetic resonance angiography without contrast, chest (excluding
myocardium) Z2 Q3

Medicare Statute 1833(t)(2)

❂ C8911 Magnetic resonance angiography without contrast followed by with
contrast, chest (excluding myocardium) Z2 Q3

Medicare Statute 1833(t)(2)

❂ C8912 Magnetic resonance angiography with contrast, lower extremity
Z2 Q3
Medicare Statute 1833(t)(2)
❂ C8913 Magnetic resonance angiography without contrast, lower extremity
Z2 Q3

Medicare Statute 1833(t)(2)

❂ C8914 Magnetic resonance angiography without contrast followed by with
contrast, lower extremity Z2 Q3
 Medicare Statute 1833(t)(2)
❂ C8918 Magnetic resonance angiography with contrast, pelvis Z2 Q3

Medicare Statute 1833(t)(2)

❂ C8919 Magnetic resonance angiography without contrast, pelvis
Z2 Q3
Medicare Statute 1833(t)(2)
❂ C8920 Magnetic resonance angiography without contrast followed by with
contrast, pelvis Z2 Q3

Medicare Statute 1833(t)(2)

Transthoracic and Transesophageal Echocardiography

❂ C8921 Transthoracic echocardiography with contrast, or without contrast
followed by with contrast, for congenital cardiac anomalies;
complete S

Medicare Statute 1833(t)(2)

Coding Clinic: 2012, Q3, P8
❂ C8922 Transthoracic echocardiography with contrast, or without contrast
followed by with contrast, for congenital cardiac anomalies; follow-
up or limited study S

Medicare Statute 1833(t)(2)

Coding Clinic: 2012, Q3, P8
❂ C8923 Transthoracic echocardiography with contrast, or without contrast
followed by with contrast, real-time with image documentation
(2D), includes M-mode recording, when performed, complete,
without spectral or color Doppler echocardiography S

Medicare Statute 1833(t)(2)

Coding Clinic: 2012, Q3, P8
❂ C8924 Transthoracic echocardiography with contrast, or without contrast
followed by with contrast, real-time with image documentation
(2D), includes M-mode recording, when performed, follow-up or
limited study S

Medicare Statute 1833(t)(2)

Coding Clinic: 2012, Q3, P8
❂ C8925 Transesophageal echocardiography (TEE) with contrast, or without
contrast followed by with contrast, real time with image
documentation (2D) (with or without M-mode recording); including
probe placement, image acquisition, interpretation and report
S
Medicare Statute 1833(t)(2)
Coding Clinic: 2012, Q3, P8
 ❂ C8926 Transesophageal echocardiography (TEE) with contrast, or without
contrast followed by with contrast, for congenital cardiac anomalies;
including probe placement, image acquisition, interpretation and
report S

Medicare Statute 1833(t)(2)

Coding Clinic: 2012, Q3, P8
❂ C8927 Transesophageal echocardiography (TEE) with contrast, or without
contrast followed by with contrast, for monitoring purposes,
including probe placement, real time 2-dimensional image
acquisition and interpretation leading to ongoing (continuous)
assessment of (dynamically changing) cardiac pumping function
and to therapeutic measures on an immediate time basis S

Medicare Statute 1833(t)(2)

Coding Clinic: 2012, Q3, P8
❂ C8928 Transthoracic echocardiography with contrast, or without contrast
followed by with contrast, real-time with image documentation
(2D), includes M-mode recording, when performed, during rest and
cardiovascular stress test using treadmill, bicycle exercise and/or
pharmacologically induced stress, with interpretation and report
S
Medicare Statute 1833(t)(2)
Coding Clinic: 2012, Q3, P8
❂ C8929 Transthoracic echocardiography with contrast, or without contrast
followed by with contrast, real-time with image documentation
(2D), includes M-mode recording, when performed, complete, with
spectral Doppler echocardiography, and with color flow Doppler
echocardiography S

Medicare Statute 1833(t)(2)

Coding Clinic: 2012, Q3, P8
❂ C8930 Transthoracic echocardiography, with contrast, or without contrast
followed by with contrast, real-time with image documentation
(2D), includes M-mode recording, when performed, during rest and
cardiovascular stress test using treadmill, bicycle exercise and/or
pharmacologically induced stress, with interpretation and report;
including performance of continuous electrocardiographic
monitoring, with physician supervision S

Medicare Statute 1833(t)(2)

Coding Clinic: 2012, Q3, P8

Magnetic Resonance Angiography: Spine and Upper Extremities

 ❂ C8931 Magnetic resonance angiography with contrast, spinal canal and
contents Z2 Q3

Medicare Statute 1833(t)

❂ C8932 Magnetic resonance angiography without contrast, spinal canal and
contents Z2 Q3

Medicare Statute 1833(t)

❂ C8933 Magnetic resonance angiography without contrast followed by with
contrast, spinal canal and contents Z2 Q3

Medicare Statute 1833(t)

❂ C8934 Magnetic resonance angiography with contrast, upper extremity
Z2 Q3
Medicare Statute 1833(t)
❂ C8935 Magnetic resonance angiography without contrast, upper extremity
Z2 Q3
Medicare Statute 1833(t)
❂ C8936 Magnetic resonance angiography without contrast followed by with
contrast, upper extremity Z2 Q3

Medicare Statute 1833(t)

❂ C8937 Computer-aided detection, including computer algorithm analysis of
breast MRI image data for lesion detection/characterization,
pharmacokinetic analysis, with further physician review for
interpretation (list separately in addition to code for primary
procedure) N

Medicare Statute 1833(t)

Drugs and Biologicals

❂ C8957 Intravenous infusion for therapy/diagnosis; initiation of prolonged
infusion (more than 8 hours), requiring use of portable or
implantable pump S

Medicare Statute 1833(t)

Coding Clinic: 2008, Q3, P8
❂ C9034 Injection, dexamethasone 9%, intraocular, 1 mcg G

Medicare Statute 1833(t)

❂ C9046 Cocaine hydrochloride nasal solution for topical administration, 1
mg K2 G

❂ C9047 Injection, caplacizumab-yhdp, 1 mg K2 G

❂ C9061 Injection, teprotumumab-trbw, 10 mg

 ❂ C9063 Injection, eptinezumab-jjmr, 1 mg
❂ C9067 Gallium ga-68, dotatoc, diagnostic, 0.01 mci K2 G

❂ C9084 injection, loncastuximab tesirine-lpyl, 0.1 mg K2 D

❂ C9085 Injection, avalglucosidase alfa-ngpt, 4 mg K2 G

❂ C9086 Injection, anifrolumab-fnia, 1 mg K2 G

❂ C9087 Injection, cyclophosphamide, (auromedics), 10 mg K2 G

❂ C9088 Instillation, bupivacaine and meloxicam, 1 mg/0.03 mg K2 N

❂ C9089 Bupivacaine, collagen-matrix implant, 1 mg K2 N

▶ ✽ C9101 Injection, oliceridine, 0.1 mg K2 N

❂ C9113 Injection, pantoprazole sodium, per vial N1 N

Medicare Statute 1833(t)

▶ ✽ C9143 Cocaine hydrochloride nasal solution (numbrino), 1 mg N

▶ ✽ C9144 Injection, bupivacaine (posimir), 1 mg K2 N

❂ C9248 Injection, clevidipine butyrate, 1 mg N1 N

Medicare Statute 1833(t)

❂ C9250 Human plasma fibrin sealant, vapor-heated, solvent-detergent
(ARTISS), 2 ml K2 K

Example of diagnosis codes to be reported with C9250: T20.00-

T25.799.
Medicare Statute 621MMA
❂ C9254 Injection, lacosamide, 1 mg N1 N

Medicare Statute 621MMA

❂ C9257 injection, bevacizumab, 0.25 mg K2 K

Medicare Statute 1833(t)

❂ C9285 Lidocaine 70 mg/tetracaine 70 mg, per patch N1 N

Medicare Statute 1833(t)

Coding Clinic: 2011, Q3, P9
❂ C9290 Injection, bupivacine liposome, 1 mg N1 N

Medicare Statute 1833(t)

❂ C9293 Injection, glucarpidase, 10 units K2 K

Medicare Statute 1833(t)

❂ C9352 Microporous collagen implantable tube (NeuraGen Nerve Guide),
per centimeter length N1 N

Medicare Statute 621MMA

❂ C9353 Microporous collagen implantable slit tube (NeuraWrap Nerve
Protector), per centimeter length N1 N

Medicare Statute 621MMA

❂ C9354 Acellular pericardial tissue matrix of non-human origin (Veritas),
per square centimeter N1 N

Medicare Statute 621MMA

❂ C9355 Collagen nerve cuff (NeuroMatrix), per 0.5 centimeter length
N1 N
Medicare Statute 621MMA
❂ C9356 Tendon, porous matrix of cross-linked collagen and
glycosaminoglycan matrix (TenoGlide Tendon Protector Sheet), per
square centimeter N1 N

Medicare Statute 621MMA

❂ C9358 Dermal substitute, native, nondenatured collagen, fetal bovine origin
(SurgiMend Collagen Matrix), per 0.5 square centimeters
N1 N
Medicare Statute 621MMA
Coding Clinic: 2013, Q3, P9; 2012, Q2, P7
❂ C9359 Porous purified collagen matrix bone void filler (Integra Mozaik
Osteoconductive Scaffold Putty, Integra OS Osteoconductive
Scaffold Putty), per 0.5 cc N1 N

Medicare Statute 1833(t)

Coding Clinic: 2015, Q3, P2
❂ C9360 Dermal substitute, native, nondenatured collagen, neonatal bovine
origin (SurgiMend Collagen Matrix), per 0.5 square centimeters
N1 N
Medicare Statute 621MMA
Coding Clinic: 2012, Q2, P7
❂ C9361 Collagen matrix nerve wrap (NeuroMend Collagen Nerve Wrap),
per 0.5 centimeter length N1 N

Medicare Statute 621MMA

❂ C9362 Porous purified collagen matrix bone void filler (Integra Mozaik
Osteoconductive Scaffold Strip), per 0.5 cc N1 N

Medicare Statute 621MMA

Coding Clinic: 2010, Q2, P8
❂ C9363 Skin substitute, Integra Meshed Bilayer Wound Matrix, per square
centimeter N1 N

Medicare Statute 621MMA

Coding Clinic: 2012, Q2, P7; 2010, Q2, P8
 ❂ C9364 Porcine implant, Permacol, per square centimeter N1 N

Medicare Statute 621MMA

❂ C9399 Unclassified drugs or biologicals K7 A

Medicare Statute 621MMA

Coding Clinic: 2017, Q1, P1-3, P8; 2016, Q4, P10; 2014, Q2, P8; 2013, Q2, P3; 2010,
Q3, P8
❂ C9460 Injection, cangrelor, 1 mg K2 G

Medicare Statute 1833(t)

❂ C9462 Injection, delafloxacin, 1 mg K2 G

Medicare Statute 1833(t)

❂ C9482 Injection, sotalol hydrochloride, 1 mg K2 G

Medicare Statute 1833(t)

Coding Clinic: 2016, Q4, P9
❂ C9488 Injection, conivaptan hydrochloride, 1 mg K2 G

Medicare Statute 1833(t)

Percutaneous Transcatheter and Transluminal Coronary Procedures

❂ C9600 Percutaneous transcatheter placement of drug-eluting intracoronary
stent(s), with coronary angioplasty when performed; a single major
coronary artery or branch J1

Medicare Statute 1833(t)

❂ C9601 Percutaneous transcatheter placement of drug-eluting intracoronary
stent(s), with coronary angioplasty when performed; each additional
branch of a major coronary artery (list separately in addition to code
for primary procedure) N

Medicare Statute 1833(t)

❂ C9602 Percutaneous transluminal coronary atherectomy, with drug-eluting
intracoronary stent, with coronary angioplasty when performed; a
single major coronary artery or branch J1

Medicare Statute 1833(t)

❂ C9603 Percutaneous transluminal coronary atherectomy, with drug-eluting
intracoronary stent, with coronary angioplasty when performed;
each additional branch of a major coronary artery (list separately in
addition to code for primary procedure) N

Medicare Statute 1833(t)

❂ C9604 Percutaneous transluminal revascularization of or through coronary
artery bypass graft (internal mammary, free arterial, venous), any
 combination of drug-eluting intracoronary stent, atherectomy and
angioplasty, including distal protection when performed; a single
vessel J1

❂ C9605 Percutaneous transluminal revascularization of or through coronary

artery bypass graft (internal mammary, free arterial, venous), any
combination of drug-eluting intracoronary stent, atherectomy and
angioplasty, including distal protection when performed; each
additional branch subtended by the bypass graft (list separately in
addition to code for primary procedure) N

Medicare Statute 1833(t)

❂ C9606 Percutaneous transluminal revascularization of acute total/subtotal
occlusion during acute myocardial infarction, coronary artery or
coronary artery bypass graft, any combination of drug-eluting
intracoronary stent, atherectomy and angioplasty, including
aspiration thrombectomy when performed, single vessel J1

Medicare Statute 1833(t)

❂ C9607 Percutaneous transluminal revascularization of chronic total
occlusion, coronary artery, coronary artery branch, or coronary
artery bypass graft, any combination of drug-eluting intracoronary
stent, atherectomy and angioplasty; single vessel J1

Medicare Statute 1833(t)

❂ C9608 Percutaneous transluminal revascularization of chronic total
occlusion, coronary artery, coronary artery branch, or coronary
artery bypass graft, any combination of drug-eluting intracoronary
stent, atherectomy and angioplasty; each additional coronary artery,
coronary artery branch, or bypass graft (list separately in addition to
code for primary procedure) N

Medicare Statute 1833(t)

Therapeutic Services and Supplies

❂ C9725 Placement of endorectal intracavitary applicator for high intensity
brachytherapy T

Medicare Statute 1833(t)

❂ C9726 Placement and removal (if performed) of applicator into breast for
intraoperative radiation therapy, add-on to primary breast procedure
N
Medicare Statute 1833(t)
❂ C9727 Insertion of implants into the soft palate; minimum of three implants
 T

Medicare Statute 1833(t)

❂ C9728 Placement of interstitial device(s) for radiation therapy/surgery
guidance (e.g., fiducial markers, dosimeter), for other than the
following sites (any approach): abdomen, pelvis, prostate,
retroperitoneum, thorax, single or multiple S

Medicare Statute 1833(t)

Coding Clinic: 2018, Q2, P4
❂ C9733 Non-ophthalmic fluorescent vascular angiography Q2

Medicare Statute 1833(t)

Coding Clinic: 2012, Q1, P7
❂ C9734 Focused ultrasound ablation/therapeutic intervention, other than
uterine leiomyomata, with magnetic resonance (MR) guidance
J1
Medicare Statute 1833(t)
❂ C9738 Adjunctive blue light cystoscopy with fluorescent imaging agent
(list separately in addition to code for primary procedure) N1 N

Medicare Statute 1833(t)

❂ C9739 Cystourethroscopy, with insertion of transprostatic implant; 1 to 3
implants J1

Medicare Statute 1833(t)

Coding Clinic: 2014, Q2, P6
❂ C9740 Cystourethroscopy, with insertion of transprostatic implant; 4 or
more implants J1

Medicare Statute 1833(t)

Coding Clinic: 2014, Q2, P6
❂ C9751 Bronchoscopy, rigid or flexible, transbronchial ablation of lesion(s)
by microwave energy, including fluoroscopic guidance, when
performed, with computed tomography acquisition(s) and 3-D
rendering, computer-assisted, image-guided navigation, and
endobronchial ultrasound (EBUS) guided transtracheal and/or
transbronchial sampling (e.g., aspiration[s]/biopsy[ies]) and all
mediastinal and/or hilar lymph node stations or structures and
therapeutic intervention(s) T

Medicare Statute 1833(t)

❂ C9756 Intraoperative near-infrared fluorescence lymphatic mapping of
lymph node(s) (sentinel or tumor draining) with administration of
indocyanine green (ICG) (list separately in addition to code for
 primary procedure) N
Coding Clinic: 2021, Q1, P9
❂ C9757 Laminotomy (hemilaminectomy), with decompression of nerve
root(s), including partial facetectomy, foraminotomy and excision of
herniated intervertebral disc, and repair of annular defect with
implantation of bone anchored annular closure device, including
annular defect measurement, alignment and sizing assessment, and
image guidance; 1 interspace, lumbar J1

❂ C9758 Blinded procedure for NYHA class III/IV heart failure; transcatheter
implantation of interatrial shunt or placebo control, including right
heart catheterization, trans-esophageal echocardiography
(TEE)/intracardiac echocardiography (ICE), and all imaging with or
without guidance (e.g., ultrasound, fluoroscopy), performed in an
approved investigational device exemption (IDE) study T

❂ C9759 Transcatheter intraoperative blood vessel microinfusion(s) (e.g.,

intraluminal, vascular wall and/or perivascular) therapy, any vessel,
including radiological supervision and interpretation, when
performed N

❂ C9760 Non-randomized, non-blinded procedure for NYHA class ii, iii, iv

heart failure; transcatheter implantation of interatrial shunt,
including right and left heart catheterization, transeptal puncture,
trans-esophageal echocardiography (tee)/intracardiac
echocardiography (ice), and all imaging with or without guidance
(e.g., ultrasound, fluoroscopy), performed in an approved
investigational device exemption (ide) study T

❂ C9761 Cystourethroscopy, with ureteroscopy and/or pyeloscopy, with

lithotripsy, and ureteral catheterization for steerable vacuum
aspiration of the kidney, collecting system, ureter, bladder, and
urethra if applicable (must use a steerable ureteral catheter) J1

❂ C9762 Cardiac magnetic resonance imaging for morphology and function,

quantification of segmental dysfunction; with strain imaging Z2 Q3
❂ C9763 Cardiac magnetic resonance imaging for morphology and function,
quantification of segmental dysfunction; with stress imaging Z2 Q3
❂ C9764 Revascularization, endovascular, open or percutaneous, any
vessel(s); with intravascular lithotripsy, includes angioplasty within
the same vessel(s), when performed J1

❂ C9765 Revascularization, endovascular, open or percutaneous, any

vessel(s); with intravascular lithotripsy, and transluminal stent
placement(s), includes angioplasty within the same vessel(s), when
 performed J1

❂ C9766 Revascularization, endovascular, open or percutaneous, any

vessel(s); with intravascular lithotripsy and atherectomy, includes
angioplasty within the same vessel(s), when performed
❂ C9767 Revascularization, endovascular, open or percutaneous, any
vessel(s); with intravascular lithotripsy and transluminal stent
placement(s), and atherectomy, includes angioplasty within the same
vessel(s), when performed J1

❂ C9768 Endoscopic ultrasound-guided direct measurement of hepatic

portosystemic pressure gradient by any method (list separately in
addition to code for primary procedure) N

❂ C9769 Cystourethroscopy, with insertion of temporary prostatic

implant/stent with fixation/anchor and incisional struts N

❂ C9770 Vitrectomy, mechanical, pars plana approach, with subretinal

injection of pharmacologic/biologic agent T

❂ C9771 Nasal/sinus endoscopy, cryoablation nasal tissue(s) and/or nerve(s),

unilateral or bilateral J1

❂ C9772 Revascularization, endovascular, open or percutaneous,

tibial/peroneal artery(ies), with intravascular lithotripsy, includes
angioplasty within the same vessel(s), when performed J1

❂ C9973 Revascularization, endovascular, open or percutaneous,

tibial/peroneal artery(ies); with intravascular lithotripsy, and
transluminal stent placement(s), includes angioplasty within the
same vessel(s), when performed J1

❂ C9774 Revascularization, endovascular, open or percutaneous,

tibial/peroneal artery(ies); with intravascular lithotripsy and
atherectomy, includes angioplasty within the same vessel(s), when
performed J1

❂ C9775 Revascularization, endovascular, open or percutaneous,

tibial/peroneal artery(ies); with intravascular lithotripsy and
transluminal stent placement(s), and atherectomy, includes
angioplasty within the same vessel(s), when performed J1

❂ C9776 Intraoperative near-infrared fluorescence imaging of major extra-

hepatic bile duct(s) (e.g., cystic duct, common bile duct and
common hepatic duct) with intravenous administration of
indocyanine green (icg) (list separately in addition to code for
primary procedure)
 ❂ C9777 Esophageal mucosal integrity testing by electrical impedance,
transoral, includes esophagoscopy or esophagogastroduodenoscopy
❂ C9778 Colpopexy, vaginal; minimally invasive extra-peritoneal approach
(sacrospinous)
❂ C9779 Endoscopic submucosal dissection (esd), including endoscopy or
colonoscopy, mucosal closure, when performed J1

❂ C9780 Insertion of central venous catheter through central venous

occlusion via inferior and superior approaches (e.g., inside-out
technique), including imaging guidance S

❂ C9803 Hospital outpatient clinic visit specimen collection for severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus
disease [COVID-19]), any specimen source Q1

❂ C9898 Radiolabeled product provided during a hospital inpatient stay

N
❂ C9899 Implanted prosthetic device, payable only for inpatients who do not
have inpatient coverage A

Medicare Statute 1833(t)

DENTAL PROCEDURES (D0000-D9999)

Diagnostic (D0120-D0999)
Clinical Oral Evaluations
D0120 Periodic oral evaluation - established patient E1

An evaluation performed on a patient of record to determine any

changes in the patient’s dental and medical health status since a
previous comprehensive or periodic evaluation. This includes an
oral cancer evaluation, periodontal screening where indicated, and
may require interpretation of information acquired through
additional diagnostic procedures. The findings are discussed with
the patient. Report additional diagnostic procedures separately.
D0140 Limited oral evaluation - problem focused E1

An evaluation limited to a specific oral health problem or complaint.

This may require interpretation of information acquired through
additional diagnostic procedures. Report additional diagnostic
procedures separately. Definitive procedures may be required on the
same date as the evaluation. Typically, patients receiving this type of
evaluation present with a specific problem and/or dental
emergencies, trauma, acute infections, etc.
D0145 Oral evaluation for a patient under three years of age and counseling
with primary caregiver E1

Diagnostic services performed for a child under the age of three,

preferably within the first six months of the eruption of the first
primary tooth, including recording the oral and physical health
history, evaluation of caries susceptibility, development of an
appropriate preventive oral health regimen and communication with
and counseling of the child’s parent, legal guardian and/or primary
caregiver.
D0150 Comprehensive oral evaluation - new or established patient S

Used by a general dentist and/or a specialist when evaluating a

patient comprehensively. This applies to new patients; established
patients who have had a significant change in health conditions or
other unusual circumstances, by report, or established patients who
have been absent from active treatment for three or more years. It is
a thorough evaluation and recording of the extraoral and intraoral
hard and soft tissues. It may require interpretation of information
acquired through additional diagnostic procedures. Additional
diagnostic procedures should be reported separately. This includes
an evaluation for oral cancer, the evaluation and recording of the
patient’s dental and medical history and a general health assessment.
It may include the evaluation and recording of dental caries, missing
or unerupted teeth, restorations, existing prostheses, occlusal
relationships, periodontal conditions (including periodontal
screening and/or charting), hard and soft tissue anomalies, etc.
D0160 Detailed and extensive oral evaluation - problem focused, by report
E1
A detailed and extensive problem focused evaluation entails
extensive diagnostic and cognitive modalities based on the findings
of a comprehensive oral evaluation. Integration of more extensive
diagnostic modalities to develop a treatment plan for a specific
problem is required. The condition requiring this type of evaluation
should be described and documented. Examples of conditions
requiring this type of evaluation may include dentofacial anomalies,
complicated perioprosthetic conditions, complex
temporomandibular dysfunction, facial pain of unknown origin,
conditions requiring multi-disciplinary consultation, etc.
D0170 Re-evaluation - limited, problem focused (established patient; not
postoperative visit) E1

Assessing the status of a previously existing condition. For example:

 a traumatic injury where no treatment was rendered but patient
needs follow-up monitoring; evaluation for undiagnosed continuing
pain; soft tissue lesion requiring follow-up evaluation.
D0171 Re-evaluation - post-operative office visit E1

D0180 Comprehensive periodontal evaluation - new or established patient

E1
This procedure is indicated for patients showing signs or symptoms
of periodontal disease and for patients with risk factors such as
smoking or diabetes. It includes evaluation of periodontal
conditions, probing and charting, an evaluation for oral cancer, the
evaluation and recording of the patient’s dental and medical history
and general health assessment. It may include the evaluation and
recording of dental caries, missing or unerupted teeth, restorations,
and occlusal relationships.

Pre-Diagnostic Services
D0190 Screening of a patient E1

A screening, including state or federally mandated screenings, to

determine an individual’s need to be seen by a dentist for diagnosis.
D0191 Assessment of a patient E1

A limited clinical inspection that is performed to identify possible

signs of oral or systemic disease, malformation, or injury, and the
potential need for referral for diagnosis and treatment.

Diagnostic Imaging
D0210 Intraoral - complete series of radiographic images E1

A radiographic survey of the whole mouth, intended to display the

crowns and roots of all teeth, periapical areas, interproximal areas
and alveolar bone including edentulous areas.
Cross Reference 70320
D0220 Intraoral - periapical first radiographic image E1

Cross Reference 70300

D0230 Intraoral - periapical each additional radiographic image E1

Cross Reference 70310

D0240 Intraoral - occlusal radiographic image S

D0250 Extra-oral — 2D projection radiographic image created using a

stationary radiation source, detector S
 These images include, but are not limited to: Lateral Skull;
Posterior-Anterior Skull; Submentovertex; Waters; Reverse Tomes;
Oblique Mandibular Body; Lateral Ramus.
D0251 Extra-oral posterior dental radiographic image Q1

Image limited to exposure of complete posterior teeth in both dental

arches. This is a unique image that is not derived from another
image.
D0270 Bitewing - single radiographic image S

D0272 Bitewings - two radiographic images S

D0273 Bitewings - three radiographic images E1

D0274 Bitewings - four radiographic images S

D0277 Vertical bitewings - 7 to 8 radiographic images S

This does not constitute a full mouth intraoral radiographic series.

D0310 Sialography E1

Cross Reference 70390

D0320 Temporomandibular joint arthrogram, including injection E1

Cross Reference 70332

D0321 Other temporomandibular joint radiographic image, by report E1

Cross Reference 76499

D0322 Tomographic survey E1

D0330 Panoramic radiographic image E1

Cross Reference 70320

D0340 2D cephalometric radiographic image - acquisition, measurement
and analysis E1

Image of the head made using a cephalostat to standardize anatomic

positioning, and with reproducible x-ray beam geometry.
Cross Reference 70350
D0350 2D oral/facial photographic image obtained intra-orally or
extraorally E1

D0351 3D photographic image ✖

This procedure is for dental or maxillofacial diagnostic purposes.
Not applicable for a CAD-CAM procedure.
D0364 Cone beam CT capture and interpretation with limited field of view
- less than one whole jaw E1

D0365 Cone beam CT capture and interpretation with field of view of one
full dental arch - mandible E1
 D0366 Cone beam CT capture and interpretation with field of view of one
full dental arch - maxilla, with or without cranium E1

D0367 Cone beam CT capture and interpretation with field of view of both
jaws, with or without cranium E1

D0368 Cone beam CT capture and interpretation for TMJ series including
two or more exposures E1

D0369 Maxillofacial MRI capture and interpretation E1

D0370 Maxillofacial ultrasound capture and interpretation E1

D0371 Sialoendoscopy capture and interpretation E1

▶ D0372 Intraoral tomosynthesis – comprehensive series of radiographic

images B

A radiographic survey of the whole mouth intended to display the

crowns and roots of all teeth, periapical areas, interproximal areas
and alveolar bone including edentulous areas.
▶ D0373 Intraoral tomosynthesis – bitewing radiographic image B

▶ D0374 Intraoral tomosynthesis – periapical radiographic image B

D0380 Cone beam CT image capture with limited field of view - less than
one whole jaw E1

D0381 Cone beam CT image capture with field of view of one full dental
arch - mandible E1

D0382 Cone beam CT image capture with field of view of one full dental
arch - maxilla, with or without cranium E1

D0383 Cone beam CT image capture with field of view of both jaws, with
or without cranium E1

D0384 Cone beam CT image capture for TMJ series including two or more
exposures E1

D0385 Maxillofacial MRI image capture E1

D0386 Maxillofacial ultrasound image capture E1

▶ D0387 Intraoral tomosynthesis – comprehensive series of radiographic

images – image capture only B

A radiographic survey of the whole mouth intended to display the

crowns and roots of all teeth, periapical areas, interproximal areas
and alveolar bone including edentulous areas.
▶ D0388 Intraoral tomosynthesis – bitewing radiographic image – image
capture only B

▶ D0389 Intraoral tomosynthesis – periapical radiographic image – image

 capture only B

D0391 Interpretation of diagnostic image by a practitioner not associated

with capture of the image, including report E1

D0393 Virtual treatment simulation using 3D image volume or surface scan

E1
Virtual simulation of treatment including, but not limited to, dental
implant placement, prosthetic reconstruction, orthognathic surgery
and orthodontic tooth movement.
D0394 Digital subtraction of two or more images or image volumes of the
same modality E1

To demonstrate changes that have occurred over time.

D0395 Fusion of two or more 3D image volumes of one or more modalities
E1

Tests and Examinations

D0411 HbA1c in-office point of service testing E1

D0412 Blood glucose level test - in-office using a glucose meter E1

D0414 Laboratory processing of microbial specimen to include culture and

sensitivity studies, preparation and transmission of written report
E1
D0415 Collection of microorganisms for culture and sensitivity E1

Cross Reference D0410

D0416 Viral culture B

A diagnostic test to identify viral organisms, most often herpes

virus.
D0417 Collection and preparation of saliva sample for laboratory
diagnostic testing E1

D0418 Analysis of saliva sample E1

Chemical or biological analysis of saliva sample for diagnostic

purposes.
D0419 Assessment of salivary flow by measurement E1

D0422 Collection and preparation of genetic sample material for laboratory

analysis and report E1

D0423 Genetic test for susceptibility to diseases - specimen analysis E1

Certified laboratory analysis to detect specific genetic variations

associated with increased susceptibility for diseases.
D0425 Caries susceptibility tests E1
 Not to be used for carious dentin staining.
D0431 Adjunctive pre-diagnostic test that aids in detection of mucosal
abnormalities including premalignant and malignant lesions, not to
include cytology or biopsy procedures B

D0460 Pulp vitality tests S

Includes multiple teeth and contra-lateral comparison(s), as

indicated.
D0470 Diagnostic casts E1

Also known as diagnostic models or study models.

Oral Pathology Laboratory (Use Codes D0472 – D0502)

D0472 Accession of tissue, gross examination, preparation and
transmission of written report B

To be used in reporting architecturally intact tissue obtained by

invasive means.
D0473 Accession of tissue, gross and microscopic examination, preparation
and transmission of written report B

To be used in reporting architecturally intact tissue obtained by

invasive means.
D0474 Accession of tissue, gross and microscopic examination, including
assessment of surgical margins for presence of disease, preparation
and transmission of written report B

To be used in reporting architecturally intact tissue obtained by

invasive means.
D0475 Decalcification procedure B

Procedure in which hard tissue is processed in order to allow

sectioning and subsequent microscopic examination.
D0476 Special stains for microorganisms B

Procedure in which additional stains are applied to biopsy or

surgical specimen in order to identify microorganisms.
D0477 Special stains, not for microorganisms B

Procedure in which additional stains are applied to a biopsy or

surgical specimen in order to identify such things as melanin,
mucin, iron, glycogen, etc.
D0478 Immunohistochemical stains B

A procedure in which specific antibody based reagents are applied

to tissue samples in order to facilitate diagnosis.
 D0479 Tissue in-situ hybridization, including interpretation B

A procedure which allows for the identification of nucleic acids,

DNA and RNA, in the tissue sample in order to aid in the diagnosis
of microorganisms and tumors.
D0480 Accession of exfoliative cytologic smears, microscopic
examination, preparation and transmission of written report B

To be used in reporting disaggregated, non-transepithelial cell

cytology sample via mild scraping of the oral mucosa.
D0481 Electron microscopy B

D0482 Direct immunofluorescence B

A technique used to identify immunoreactants which are localized to

the patient’s skin or mucous membranes.
D0483 Indirect immunofluorescence B

A technique used to identify circulating immunoreactants.

D0484 Consultation on slides prepared elsewhere B

A service provided in which microscopic slides of a biopsy

specimen prepared at another laboratory are evaluated to aid in the
diagnosis of a difficult case or to offer a consultative opinion at the
patient’s request. The findings are delivered by written report.
D0485 Consultation, including preparation of slides from biopsy material
supplied by referring source B

A service that requires the consulting pathologist to prepare the

slides as well as render a written report. The slides are evaluated to
aid in the diagnosis of a difficult case or to offer a consultative
opinion at the patient’s request.
D0486 Laboratory accession of transepithelial cytologic sample,
microscopic examination, preparation and transmission of written
report E1

Analysis, and written report of findings, of cytologic sample of

disaggregated transepithelial cells.
D0502 Other oral pathology procedures, by report B

Tests and Examinations

D0600 Non-ionizing diagnostic procedure capable of quantifying,
monitoring, and recording changes in structure of enamel, dentin,
and cementum S

D0601 Caries risk assessment and documentation, with a finding of low

 risk E1

Using recognized assessment tools.

D0602 Caries risk assessment and documentation, with a finding of
moderate risk E1

Using recognized assessment tools.

D0603 Caries risk assessment and documentation, with a finding of high
risk E1

Using recognized assessment tools.

D0604 Antigen testing for public health related pathogen, including
coronavirus
D0605 Antibody testing for public health related pathogen, including
coronavirus
D0701 Panoramic radiographic image – image capture only
D0702 2-D cephalometric radiographic image – image capture only
D0703 2-D oral/facial photographic image obtained intra-orally or extra-
orally – image capture only
D0704 3-D photographic image – image capture only ✖
D0705 Extra-oral posterior dental radiographic image – image capture only
Image limited to exposure of complete posterior teeth in both dental
arches.
This is a unique image that is not derived from another image.
D0706 Intraoral – occlusal radiographic image – image capture only
D0707 Intraoral – periapical radiographic image – image capture only
D0708 Intraoral – bitewing radiographic image – image capture only
Image axis may be horizontal or vertical.
D0709 Intraoral – complete series of radiographic images – image capture
only
A radiographic survey of the whole mouth intended to display the
crowns and roots of all teeth, periapical areas, interproximal areas
and alveolar bone including edentulous areas.

3D Scan
▶ D0801 3D dental surface scan – direct B

▶ D0802 3D dental surface scan – indirect B

A surface scan of a diagnostic cast.

 ▶ D0803 3D facial surface scan – direct B

▶ D0804 3D facial surface scan – indirect B

A surface scan of constructed facial features.

None
D0999 Unspecified diagnostic procedure, by report B

Used for procedure that is not adequately described by a code.

Describe procedure.

Preventative (D1110-D1999)
Dental Prophylaxis
D1110 Prophylaxis - adult E1

Removal of plaque, calculus and stains from the tooth structures and
implants in the permanent and transitional dentition. It is intended to
control local irritational factors.
D1120 Prophylaxis - child E1

Removal of plaque, calculus and stains from the tooth structures and
implants in the primary and transitional dentition. It is intended to
control local irritational factors.

Topical Fluoride Treatment (Office Procedure)

D1206 Topical application of fluoride varnish E1

D1208 Topical application of fluoride — excluding varnish E1

Other Preventative Services

D1310 Nutritional counseling for the control of dental disease E1

Counseling on food selection and dietary habits as a part of

treatment and control of periodontal disease and caries.
D1320 Tobacco counseling for the control and prevention of oral disease
E1
Tobacco prevention and cessation services reduce patient risks
of developing tobacco-related oral diseases and conditions and
improves prognosis for certain dental therapies.
D1321 Counseling for the control and prevention of adverse oral,
behavioral, and systemic health effects associated with high-risk
substance use
Counseling services may include patient education about adverse
 oral, behavioral, and systemic effects associated with high-risk
substance use and administration routes. This includes ingesting,
injecting, inhaling and vaping. Substances used in a high-risk
manner may include but are not limited to alcohol, opioids, nicotine,
cannabis, methamphetamine and other pharmaceuticals or
chemicals.
D1330 Oral hygiene instruction E1

This may include instructions for home care. Examples include

tooth brushing technique, flossing, use of special oral hygiene aids.
D1351 Sealant - per tooth E1

Mechanically and/or chemically prepared enamel surface sealed to

prevent decay.
D1352 Preventive resin restoration in a moderate to high caries risk patient
— permanent tooth E1

Conservative restoration of an active cavitated lesion in a pit or

fissure that does not extend into dentin; includes placement of a
sealant in any radiating non-carious fissures or pits.
D1353 Sealant repair — per tooth E1

D1354 Application of caries arresting medicament — per tooth E1

Conservative treatment of an active, non-symptomatic carious lesion

by topical application of a caries arresting or inhibiting medicament
and without mechanical removal of sound tooth structure.
D1355 Caries preventive medicament application – per tooth
For primary prevention or remineralization. Medicaments applied
do not include topical fluorides.

Space Maintenance (Passive Appliances)

D1510 Space maintainer - fixed - unilateral - per quadrant S

Excludes a distal shoe space maintainer.

D1516 Space Maintainer - fixed - bilateral, maxillary S

D1517 Space Maintainer - fixed - bilateral, mandibular S

D1520 Space maintainer - removable - unilateral - per quadrant S

D1526 Space maintainer - removable - bilateral, maxillary S

D1527 Space maintainer - removable - bilateral, mandibular S

D1551 Re-cement or re-bond bilateral space maintainer - maxillary S

 D1552 Re-cement or re-bond bilateral space maintainer - mandibular S

D1553 Re-cement or re-bond unilateral space maintainer - per quadrant S

D1556 Removal of fixed unilateral space maintainer - per quadrant E1

D1557 Removal of fixed bilateral space maintainer - maxillary E1

D1558 Removal of fixed bilateral space maintainer - mandibular E1

Space Maintainers
D1575 Distal shoe space maintainer - fixed - unilateral - per quadrant S

Fabrication and delivery of fixed appliance extending subgingivally

and distally to guide the eruption of the first permanent molar. Does
not include ongoing follow-up or adjustments, or replacement
appliances, once the tooth has erupted.

Vaccine administration
▶ D1781 Vaccine administration – human papillomavirus – Dose 1 E1

Gardasil 9 0.5mL intramuscular vaccine injection.

▶ D1782 Vaccine administration – human papillomavirus – Dose 2 E1

Gardasil 9 0.5mL intramuscular vaccine injection.

▶ D1783 Vaccine administration – human papillomavirus – Dose 3 E1

Gardasil 9 0.5mL intramuscular vaccine injection.

None
D1999 Unspecified preventive procedure, by report E1

Used for procedure that is not adequately described by another CDT

Code. Describe procedure.

Restorative (D2140-D2999)
Amalgam Restorations (Including Polishing)
D2140 Amalgam - one surface, primary or permanent E1

D2150 Amalgam - two surfaces, primary or permanent E1

D2160 Amalgam - three surfaces, primary or permanent E1

D2161 Amalgam - four or more surfaces, primary or permanent E1

Resin-Based Composite Restorations – Direct

D2330 Resin-based composite - one surface, anterior E1
 D2331 Resin-based composite - two surfaces, anterior E1

D2332 Resin-based composite - three surfaces, anterior E1

D2335 Resin-based composite - four or more surfaces or involving incisal

angle (anterior) E1

Incisal angle to be defined as one of the angles formed by the

junction of the incisal and the mesial or distal surface of an anterior
tooth.
D2390 Resin-based composite crown, anterior E1

Full resin-based composite coverage of tooth.

D2391 Resin-based composite - one surface, posterior E1

Used to restore a carious lesion into the dentin or a deeply eroded

area into the dentin. Not a preventive procedure.
D2392 Resin-based composite - two surfaces, posterior E1

D2393 Resin-based composite - three surfaces, posterior E1

D2394 Resin-based composite - four or more surfaces, posterior E1

Gold Foil Restorations

D2410 Gold foil - one surface E1

D2420 Gold foil - two surfaces E1

D2430 Gold foil - three surfaces E1

Inlay/Onlay Restorations
D2510 Inlay - metallic - one surface E1

D2520 Inlay - metallic - two surfaces E1

D2530 Inlay - metallic - three or more surfaces E1

D2542 Onlay - metallic - two surfaces E1

D2543 Onlay - metallic - three surfaces E1

D2544 Onlay - metallic - four or more surfaces E1

D2610 Inlay - porcelain/ceramic - one surface E1

D2620 Inlay - porcelain/ceramic - two surfaces E1

D2630 Inlay - porcelain/ceramic - three or more surfaces E1

D2642 Onlay - porcelain/ceramic - two surfaces E1

D2643 Onlay - porcelain/ceramic - three surfaces E1

D2644 Onlay - porcelain/ceramic - four or more surfaces E1

D2650 Inlay - resin-based composite - one surface E1

 D2651 Inlay - resin-based composite - two surfaces E1

D2652 Inlay - resin-based composite - three or more surfaces E1

D2662 Onlay - resin-based composite - two surfaces E1

D2663 Onlay - resin-based composite - three surfaces E1

D2664 Onlay - resin-based composite - four or more surfaces E1

Crowns – Single Restoration Only

D2710 Crown - resin-based composite (indirect) E1

D2712 Crown - 3/4 resin-based composite (indirect) E1

This procedure does not include facial veneers.

D2720 Crown - resin with high noble metal E1

D2721 Crown - resin with predominantly base metal E1

D2722 Crown - resin with noble metal E1

D2740 Crown - porcelain/ceramic E1

D2750 Crown - porcelain fused to high noble metal E1

D2751 Crown - porcelain fused to predominantly base metal E1

D2752 Crown - porcelain fused to noble metal E1

D2753 Crown - porcelain fused to titanium and titanium alloys E1

D2780 Crown - 3/4 cast high noble metal E1

D2781 Crown - 3/4 cast predominantly base metal E1

D2782 Crown - 3/4 cast noble metal E1

D2783 Crown - 3/4 porcelain/ceramic E1

This procedure does not include facial veneers.

D2790 Crown - full cast high noble metal E1

D2791 Crown - full cast predominantly base metal E1

D2792 Crown - full cast noble metal E1

D2794 Crown - titanium and titanium alloys E1

D2799 Interim crown - further treatment or completion of diagnosis

necessary prior to final impression E1

Not to be used as a temporary crown for a routine prosthetic

restoration.

Other Restorative Services

D2910 Re-cement or re-bond inlay, onlay, veneer or partial coverage
restoration E1
D2915 Re-cement or re-bond indirectly fabricated cast or prefabricated post
and core E1

D2920 Re-cement or re-bond crown E1

D2921 Reattachment of tooth fragment, incisal edge or cusp E1

D2928 Prefabricated porcelain/ceramic crown – permanent tooth

D2929 Prefabricated porcelain/ceramic crown - primary tooth E1

D2930 Prefabricated stainless steel crown - primary tooth E1

D2931 Prefabricated stainless steel crown - permanent tooth E1

D2932 Prefabricated resin crown E1

D2933 Prefabricated stainless steel crown with resin window E1

Open-face stainless steel crown with aesthetic resin facing or

veneer.
D2934 Prefabricated esthetic coated stainless steel crown - primary tooth
E1
Stainless steel primary crown with exterior esthetic coating.
D2940 Protective restoration E1

Direct placement of a restorative material to protect tooth and/or

tissue form. This procedure may be used to relieve pain, promote
healing, or prevent further deterioration. Not to be used for
endodontic access closure, or as a base or liner under a restoration.
D2941 Interim therapeutic restoration - primary dentition E1

Placement of an adhesive restorative material following caries

debridement by hand or other method for the management of early
childhood caries. Not considered a definitive restoration.
D2949 Restorative foundation for an indirect restoration E1

Placement of restorative material to yield a more ideal form,

including elimination of undercuts.
D2950 Core build-up, including any pins when required E1

Refers to building up of coronal structure when there is insufficient

retention for a separate extracoronal restorative procedure. A core
build-up is not a filler to eliminate any undercut, box form, or
concave irregularity in a preparation.
D2951 Pin retention - per tooth, in addition to restoration E1

D2952 Post and core in addition to crown, indirectly fabricated E1

Post and core are custom fabricated as a single unit.

D2953 Each additional indirectly fabricated post - same tooth E1

To be used with D2952.

 D2954 Prefabricated post and core in addition to crown E1

Core is built around a prefabricated post. This procedure includes

the core material.
D2955 Post removal E1

D2957 Each additional prefabricated post - same tooth E1

To be used with D2954.

D2960 Labial veneer (laminate) - direct E1

Refers to labial/facial direct resin bonded veneers.

D2961 Labial veneer (resin laminate) - indirect E1

Refers to labial/facial indirect resin bonded veneers.

D2962 Labial veneer (porcelain laminate) - indirect E1

Refers also to facial veneers that extend interproximally and/or

cover the incisal edge. Porcelain/ceramic veneers presently include
all ceramic and porcelain veneers.
D2971 Additional procedures to customize a crown to fit under existing
partial denture framework E1

This procedure is in addition to the separate crown procedure

documented with its own code.
D2975 Coping E1

A thin covering of the coronal portion of a tooth, usually devoid of

anatomic contour, that can be used as a definitive restoration.
D2980 Crown repair, necessitated by restorative material failure E1

D2981 Inlay repair necessitated by restorative material failure E1

D2982 Onlay repair necessitated by restorative material failure E1

D2983 Veneer repair necessitated by restorative material failure E1

D2990 Resin infiltration of incipient smooth surface lesions E1

Placement of an infiltrating resin restoration for strengthening,

stabilizing and/or limiting the progression of the lesion.

None
D2999 Unspecified restorative procedure, by report S

Use for procedure that is not adequately described by a code.

Describe procedure.

Endodontics (D3110-D3999)
Pulp Capping
 D3110 Pulp cap - direct (excluding final restoration) E1

Procedure in which the exposed pulp is covered with a dressing or

cement that protects the pulp and promotes healing and repair.
D3120 Pulp cap - indirect (excluding final restoration) E1

Procedure in which the nearly exposed pulp is covered with a

protective dressing to protect the pulp from additional injury and to
promote healing and repair via formation of secondary dentin. This
code is not to be used for bases and liners when all caries has been
removed.

Pulpotomy
D3220 Therapeutic pulpotomy (excluding final restoration) removal of pulp
coronal to the dentinocemental junction and application of
medicament E1

Pulpotomy is the surgical removal of a portion of the pulp with the

aim of maintaining the vitality of the remaining portion by means of
an adequate dressing.
– To be performed on primary or permanent teeth.
– This is not to be construed as the first stage of root canal therapy.
– Not to be used for apexogenesis.
D3221 Pulpal debridement, primary and permanent teeth E1

Pulpal debridement for the relief of acute pain prior to conventional

root canal therapy. This procedure is not to be used when
endodontic treatment is completed on the same day.
D3222 Partial pulpotomy for apexogenesis - permanent tooth with
incomplete root development E1

Removal of a portion of the pulp and application of a medicament

with the aim of maintaining the vitality of the remaining portion to
encourage continued physiological development and formation of
the root. This procedure is not to be construed as the first stage of
root canal therapy.

Endodontic Therapy on Primary Teeth

D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth
(excluding final restoration) E1

Primary incisors and cuspids.

D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth
 (excluding final restoration) E1

Primary first and second molars.

Endodontic Therapy (Including Treatment Plan, Clinical Procedures and

Follow-Up Care)
D3310 Endodontic therapy, anterior tooth (excluding final restoration)
E1
D3320 Endodontic therapy, premolar tooth (excluding final restoration)
E1
D3330 Endodontic therapy, molar (excluding final restoration) E1

D3331 Treatment of root canal obstruction; non-surgical access E1

In lieu of surgery, the formation of a pathway to achieve an apical

seal without surgical intervention because of a non-negotiable root
canal blocked by foreign bodies, including but not limited to
separated instruments, broken posts or calcification of 50% or more
of the length of the tooth root.
D3332 Incomplete endodontic therapy; inoperable, unrestorable or
fractured tooth E1

Considerable time is necessary to determine diagnosis and/or

provide initial treatment before the fracture makes the tooth
unretainable.
D3333 Internal root repair of perforation defects E1

Non-surgical seal of perforation caused by resorption and/or decay

but not iatrogenic by provider filing claim.

Endodontic Retreatment
D3346 Retreatment of previous root canal therapy - anterior E1

D3347 Retreatment of previous root canal therapy - premolar E1

D3348 Retreatment of previous root canal therapy - molar E1

Apexification/Recalcification
D3351 Apexification/recalcification - initial visit (apical closure/calcific
repair of perforations, root resorption, etc.) E1

Includes opening tooth, preparation of canal spaces, first placement

of medication and necessary radiographs. (This procedure may
include first phase of complete root canal therapy.)
D3352 Apexification/recalcification - interim medication replacement
(apical closure/calcific repair of perforations, root resorption, pulp
 space disinfection, etc.) E1

For visits in which the intra-canal medication is replaced with new

medication. Includes any necessary radiographs.
D3353 Apexification/recalcification - final visit (includes completed root
canal therapy - apical closure/calcific repair of perforations, root
resorption, etc.) E1

Includes removal of intra-canal medication and procedures

necessary to place final root canal filling material including
necessary radiographs. (This procedure includes last phase of
complete root canal therapy.)

Pulpal Regeneration
D3355 Pulpal regeneration - initial visit E1

Includes opening tooth, preparation of canal spaces, placement of

medication.
D3356 Pulpal regeneration - interim medication replacement E1

D3357 Pulpal regeneration - completion of treatment E1

Does not include final restoration.

Apicoectomy/Periradicular Services
D3410 Apicoectomy - anterior E1

For surgery on root of anterior tooth. Does not include placement of

retrograde filling material.
D3421 Apicoectomy - premolar (first root) E1

For surgery on one root of a premolar. Does not include placement

of retrograde filling material. If more than one root is treated, see
D3426.
D3425 Apicoectomy - molar (first root) E1

For surgery on one root of a molar tooth. Does not include

placement of retrograde filling material. If more than one root is
treated, see D3426.
D3426 Apicoectomy (each additional root) E1

Typically used for premolar and molar surgeries when more than
one root is treated during the same procedure. This does not include
retrograde filling material placement.
D3428 Bone graft in conjunction with periradicular surgery - per tooth,
single site E1
 Includes non-autogenous graft material.
D3429 Bone graft in conjunction with periradicular surgery - each
additional contiguous tooth in the same surgical site E1

Includes non-autogenous graft material.

D3430 Retrograde filling - per root E1

For placement of retrograde filling material during periradicular

surgery procedures. If more than one filling is placed in one root -
report as D3999 and describe.
D3431 Biologic materials to aid in soft and osseous tissue regeneration in
conjunction with periradicular surgery E1

D3432 Guided tissue regeneration, resorbable barrier, per site, in

conjunction with periradicular surgery E1

D3450 Root amputation - per root E1

Root resection of a multi-rooted tooth while leaving the crown. If

the crown is sectioned, see D3920.
D3460 Endodontic endosseous implant S

Placement of implant material, which extends from a pulpal space

into the bone beyond the end of the root.
D3470 Intentional replantation (including necessary splinting) E1

For the intentional removal, inspection and treatment of the root and
replacement of a tooth into its own socket. This does not include
necessary retrograde filling material placement.
D3471 Surgical repair of root resorption – anterior
For surgery on root of anterior tooth. Does not include placement of
restoration.
D3472 Surgical repair of root resorption – premolar
For surgery on root of premolar tooth. Does not include placement
of restoration.
D3473 Surgical repair of root resorption – molar
For surgery on root of molar tooth. Does not include placement of
restoration.
D3501 Surgical exposure of root surface without apicoectomy or repair of
root resorption – anterior
Exposure of root surface followed by observation and surgical
closure of the exposed area. Not to be used for or in conjunction
with apicoectomy or repair of root resorption.
 D3502 Surgical exposure of root surface without apicoectomy or repair of
root resorption – premolar
Exposure of root surface followed by observation and surgical
closure of the exposed area. Not to be used for or in conjunction
with apicoectomy or repair of root resorption.
D3503 Surgical exposure of root surface without apicoectomy or repair of
root resorption – molar
Exposure of root surface followed by observation and surgical
closure of the exposed area. Not to be used for or in conjunction
with apicoectomy or repair of root resorption.

Other Endodontic Procedures

D3910 Surgical procedure for isolation of tooth with rubber dam E1

D3911 Intraorifice barrier E1

Not to be used as a final restoration.

D3920 Hemisection (including any root removal), not including root canal
therapy E1

Includes separation of a multi-rooted tooth into separate sections

containing the root and the overlying portion of the crown. It may
also include the removal of one or more of those sections.
D3921 Decoronation or submergence of an erupted tooth
Intentional removal of coronal tooth structure for preservation of the
root and surrounding bone.
D3950 Canal preparation and fitting of preformed dowel or post E1

Should not be reported in conjunction with D2952, D2953, D2954

or D2957 by the same practitioner.

None
D3999 Unspecified endodontic procedure, by report S

Used for procedure that is not adequately described by a code.

Describe procedure.

Periodontics (D4210-D4999)
Surgical Services (Including Usual Postoperative Care)
D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or
tooth bounded spaces per quadrant E1

It is performed to eliminate suprabony pockets or to restore normal

 architecture when gingival enlargements or asymmetrical or
unaesthetic topography is evident with normal bony configuration.
Cross Reference 41820
D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or
tooth bounded spaces per quadrant E1

It is performed to eliminate suprabony pockets or to restore normal

architecture when gingival enlargements or asymmetrical or
unaesthetic topography is evident with normal bony configuration.
D4212 Gingivectomy or gingivoplasty to allow access for restorative
procedure, per tooth E1

D4230 Anatomical crown exposure - four or more contiguous teeth or

bounded tooth spaces per quadrant E1

This procedure is utilized in an otherwise periodontally healthy area

to remove enlarged gingival tissue and supporting bone (ostectomy)
to provide an anatomically correct gingival relationship.
D4231 Anatomical crown exposure - one to three teeth or bounded tooth
spaces per quadrant E1

This procedure is utilized in an otherwise periodontally healthy area

to remove enlarged gingival tissue and supporting bone (ostectomy)
to provide an anatomically correct gingival relationship.
D4240 Gingival flap procedure, including root planing - four or more
contiguous teeth or tooth bounded spaces per quadrant E1

A soft tissue flap is reflected or resected to allow debridement of the

root surface and the removal of granulation tissue. Osseous
recontouring is not accomplished in conjunction with this
procedure. May include open flap curettage, reverse bevel flap
surgery, modified Kirkland flap procedure, and modified Widman
surgery. This procedure is performed in the presence of moderate to
deep probing depths, loss of attachment, need to maintain esthetics,
need for increased access to the root surface and alveolar bone, or to
determine the presence of a cracked tooth, fractured root, or external
root resorption. Other procedures may be required concurrent to
D4240 and should be reported separately using their own unique
codes.
D4241 Gingival flap procedure, including root planing - one to three
contiguous teeth or tooth bounded spaces per quadrant E1

A soft tissue flap is reflected or resected to allow debridement of the

root surface and the removal of granulation tissue. Osseous
recontouring is not accomplished in conjunction with this
 procedure. May include open flap curettage, reverse bevel flap
surgery, modified Kirkland flap procedure, and modified Widman
surgery. This procedure is performed in the presence of moderate to
deep probing depths, loss of attachment, need to maintain esthetics,
need for increased access to the root surface and alveolar bone, or to
determine the presence of a cracked tooth, fractured root, or external
root resorption. Other procedures may be required concurrent to
D4241 and should be reported separately using their own unique
codes.
D4245 Apically positioned flap E1

Procedure is used to preserve keratinized gingiva in conjunction

with osseous resection and second stage implant procedure.
Procedure may also be used to preserve keratinized/attached gingiva
during surgical exposure of labially impacted teeth, and may be used
during treatment of periimplantitis.
D4249 Clinical crown lengthening - hard tissue E1

This procedure is employed to allow a restorative procedure on a

tooth with little or no tooth structure exposed to the oral cavity.
Crown lengthening requires reflection of a full thickness flap and
removal of bone, altering the crown to root ratio. It is performed in a
healthy periodontal environment, as opposed to osseous surgery,
which is performed in the presence of periodontal disease.
D4260 Osseous surgery (including elevation of a full thickness flap and
closure) - four or more contiguous teeth or tooth bounded spaces per
quadrant S

This procedure modifies the bony support of the teeth by reshaping

the alveolar process to achieve a more physiologic form during the
surgical procedure. This must include the removal of supporting
bone (ostectomy) and/or non-supporting bone (osteoplasty). Other
procedures may be required concurrent to D4260 and should be
reported using their own unique codes.
D4261 Osseous surgery (including elevation of a full thickness flap and
closure) - one to three contiguous teeth or tooth bounded spaces per
quadrant E1

This procedure modifies the bony support of the teeth by reshaping

the alveolar process to achieve a more physiologic form during the
surgical procedure. This must include the removal of supporting
bone (ostectomy) and/or non-supporting bone (osteoplasty). Other
procedures may be required concurrent to D4261 and should be
reported using their own unique codes.
D4263 Bone replacement graft - retained natural tooth - first site in
quadrant S

This procedure involves the use of grafts to stimulate periodontal

regeneration when the disease process has led to a deformity of the
bone. This procedure does not include flap entry and closure, wound
debridement, osseous contouring, or the placement of biologic
materials to aid in osseous tissue regeneration or barrier membranes.
Other separate procedures delivered concurrently are documented
with their own codes. Not to be reported for an edentulous space or
an extraction site.
D4264 Bone replacement graft - retained natural tooth - each additional site
in quadrant S

This procedure involves the use of grafts to stimulate periodontal

regeneration when the disease process has led to a deformity of the
bone. This procedure does not include flap entry and closure, wound
debridement, osseous contouring, or the placement of biologic
materials to aid in osseous tissue regeneration or barrier membranes.
This procedure is performed concurrently with one or more bone
replacement grafts to document the number of sites involved. Not to
be reported for an edentulous space or an extraction site.
D4265 Biologic materials to aid in soft and osseous tissue regeneration, per
site E1

Biologic materials may be used alone or with other regenerative

substrates such as bone and barrier membranes, depending upon
their formulation and the presentation of the periodontal defect. This
procedure does not include surgical entry and closure, wound
debridement, osseous contouring, or the placement of graft materials
and/or barrier membranes. Other separate procedures may be
required concurrent to D4265 and should be reported using their
own unique codes.
D4266 Guided tissue regeneration - resorbable barrier, per site E1

This procedure does not include flap entry and closure, or, when
indicated, wound debridement, osseous contouring, bone
replacement grafts, and placement of biologic materials to aid in
osseous regeneration. This procedure can be used for periodontal
defects around natural teeth.
D4267 Guided tissue regeneration - nonresorbable barrier, per site,
(includes membrane removal) E1

This procedure does not include flap entry and closure, or, when
 indicated, wound debridement, osseous contouring, bone
replacement grafts, and placement of biologic materials to aid in
osseous regeneration. This procedure can be used for periodontal
defects around natural teeth.
D4268 Surgical revision procedure, per tooth S

This procedure is to refine the results of a previously provided

surgical procedure. This may require a surgical procedure to modify
the irregular contours of hard or soft tissue. A mucoperiosteal flap
may be elevated to allow access to reshape alveolar bone. The flaps
are replaced or repositioned and sutured.
D4270 Pedicle soft tissue graft procedure S

A pedicle flap of gingiva can be raised from an edentulous ridge,

adjacent teeth, or from the existing gingiva on the tooth and moved
laterally or coronally to replace alveolar mucosa as marginal tissue.
The procedure can be used to cover an exposed root or to eliminate
a gingival defect if the root is not too prominent in the arch.
D4273 Autogenous connective tissue graft procedure (including donor and
recipient surgical sites) first tooth, implant, or edentulous tooth
position in graft S

There are two surgical sites. The recipient site utilizes a split
thickness incision, retaining the overlapping flap of gingiva and/or
mucosa. The connective tissue is dissected from a separate donor
site leaving an epithelialized flap for closure.
D4274 Mesial/distal wedge procedure, single tooth (when not performed in
conjuction with surgical procedures in the same anatomical area)
This procedure is performed in an edentulous area adjacent to a E1
tooth, allowing removal of a tissue wedge to gain access for
debridement, permit close flap adaptation, and reduce pocket
depths.
D4275 Non-autogenous connective tissue graft (including recipient site and
donor material) first tooth, implant, or edentulous tooth position in
graft E1

There is only a recipient surgical site utilizing split thickness

incision, retaining the overlaying flap of gingiva and/or mucosa. A
donor surgical site is not present.
D4276 Combined connective tissue and pedicle graft, per tooth E1

Advanced gingival recession often cannot be corrected with a single

procedure. Combined tissue grafting procedures are needed to
achieve the desired outcome.
 D4277 Free soft tissue graft procedure (including recipient and donor
surgical sites) first tooth, implant or edentulous tooth position in
graft E1

D4278 Free soft tissue graft procedure (including recipient and donor
surgical sites) each additional contiguous tooth, implant or
edentulous tooth position in same graft site E1

Used in conjunction with D4277.

D4283 Autogenous connective tissue graft procedure (including donor and
recipient surgical sites) - each additional contiguous tooth, implant
or edentulous tooth position in same graft site E1

Used in conjunction with D4273.

D4285 Non-autogenous connective tissue graft procedure (including
recipient surgical site and donor material) - each additional
contiguous tooth, implant or edentulous tooth position in same graft
site E1

Used in conjunction with D4275.

▶ D4286 Removal of non-resorbable barrier B

Non-Surgical Periodontal Services

D4322 Splint – intra-coronal; natural teeth or prosthetic crowns E1

Additional procedure that physically links individual teeth or

prosthetic crowns to provide stabilization and additional strength.
D4323 Splint – extra-coronal; natural teeth or prosthetic crowns E1

Additional procedure that physically links individual teeth or

prosthetic crowns to provide stabilization and additional strength.
D4341 Periodontal scaling and root planing - four or more teeth per
quadrant E1

This procedure involves instrumentation of the crown and root

surfaces of the teeth to remove plaque and calculus from these
surfaces. It is indicated for patients with periodontal disease and is
therapeutic, not prophylactic, in nature. Root planing is the
definitive procedure designed for the removal of cementum and
dentin that is rough, and/or permeated by calculus or contaminated
with toxins or microorganisms. Some soft tissue removal occurs.
This procedure may be used as a definitive treatment in some stages
of periodontal disease and/or as a part of pre-surgical procedures in
others.
D4342 Periodontal scaling and root planing - one to three teeth, per
 quadrant E1

This procedure involves instrumentation of the crown and root

surfaces of the teeth to remove plaque and calculus from these
surfaces. It is indicated for patients with periodontal disease and is
therapeutic, not prophylactic, in nature. Root planing is the
definitive procedure designed for the removal of cementum and
dentin that is rough, and/or permeated by calculus or contaminated
with toxins or microorganisms. Some soft tissue removal occurs.
This procedure may be used as a definitive treatment in some stages
of periodontal disease and/or as a part of pre-surgical procedures in
others.
D4346 Scaling in presence of generalized moderate or severe gingival
inflammation - full mouth, after oral evaluation E1

The removal of plaque, calculus and stains from supra- and sub-
gingival tooth surfaces when there is generalized moderate or severe
gingival inflammation in the absence of periodontitis. It is indicated
for patients who have swollen, inflamed gingiva, generalized
suprabony pockets, and moderate to severe bleeding on probing.
Should not be reported in conjunction with prophylaxis, scaling and
root planing, or debridement procedures.
D4355 Full mouth debridement to enable a comprehensive periodontal
evaluation and diagnosis on a subsequent visit S

Full mouth debridement involves the preliminary removal of plaque

and calculus that interferes with the ability of the dentist to perform
a comprehensive oral evaluation. Not to be completed on the same
day as D0150, D0160, or D0180.
D4381 Localized delivery of antimicrobial agents via a controlled release
vehicle into diseased crevicular tissue, per tooth S

FDA approved subgingival delivery devices containing

antimicrobial medication(s) are inserted into periodontal pockets to
suppress the pathogenic microbiota. These devices slowly release
the pharmacological agents so they can remain at the intended site
of action in a therapeutic concentration for a sufficient length of
time.

Other Periodontal Services

D4910 Periodontal maintenance E1

This procedure is instituted following periodontal therapy and

continues at varying intervals, determined by the clinical evaluation
 of the dentist, for the life of the dentition or any implant
replacements. It includes removal of the bacterial plaque and
calculus from supragingival and subgingival regions, site specific
scaling and root planing where indicated, and polishing the teeth. If
new or recurring periodontal disease appears, additional diagnostic
and treatment procedures must be considered.
D4920 Unscheduled dressing change (by someone other than treating
dentist or their staff) E1

D4921 Gingival irrigation with a medicinal agent - per quadrant E1

Irrigation of gingival pockets with medicinal agent. Not to be used

to report use of mouth rinses or noninvasive chemical debridement.

None
D4999 Unspecified periodontal procedure, by report E1

Use for procedure that is not adequately described by a code.

Describe procedure.

Prosthodontics (removable)
Complete Dentures (Including Routine Post-Delivery Care)
D5110 Complete denture - maxillary E1

D5120 Complete denture - mandibular E1

D5130 Immediate denture - maxillary E1

Includes limited follow-up care only; does not include required

future rebasing/relining procedure(s).
D5140 Immediate denture - mandibular E1

Includes limited follow-up care only; does not include required

future rebasing/relining procedure(s).

Partial Dentures (Including Routine Post-Delivery Care)

D5211 Maxillary partial denture-resin base (including retentive/clasping
materials, rests and teeth) E1

Includes acrylic resin base denture with resin or wrought wire

clasps.
D5212 Mandibular partial denture-resin base (including, retentive/clasping
materials, rests and teeth) E1

Includes acrylic resin base denture with resin or wrought wire

clasps.
D5213 Maxillary partial denture - cast metal framework with resin denture
bases (including retentive/clasping materials, rests and teeth) E1

D5214 Mandibular partial denture - cast metal framework with resin

denture bases (including retentive/clasping materials, rests and
teeth) E1

D5221 Immediate maxillary partial denture - resin base (including

retentive/clasping materials, rests and teeth) E1

Includes limited follow-up care only; does not include future

rebasing/relining procedure(s).
D5222 Immediate mandibular partial denture - resin base (including
retentive/clasping materials, rests and teeth) E1

Includes limited follow-up care only; does not include future

rebasing/relining procedure(s).
D5223 Immediate maxillary partial denture - cast metal framework with
resin denture bases (including retentive/clasping materials, rests and
teeth) E1

Includes limited follow-up care only; does not include future

rebasing/relining procedure(s).
D5224 Immediate mandibular partial denture - cast metal framework with
resin denture bases (including retentive/clasping materials, rests and
teeth) E1

Includes limited follow-up care only; does not include future

rebasing/relining procedure(s).
D5225 Maxillary partial denture - flexible base (including
retentive/clasping materials, rests and teeth) E1

D5226 Mandibular partial denture - flexible base (including

retentive/clasping materials, rests and teeth) E1

D5227 Immediate maxillary partial denture - flexible base (including any

clasps, rests and teeth) E1

D5228 Immediate mandibular partial denture - flexible base (including any

clasps, rests and teeth) E1

D5282 Removable unilateral partial denture - one piece cast metal

(including retentive/clasping materials, and teeth), maxillary E1

D5283 Removable unilateral partial denture - one piece cast metal

(including retentive/clasping materials, rests, and teeth), mandibular
E1
D5284 Removable unilateral partial denture - one piece flexible base
(including retentive/clasping materials, rests, rests, and teeth) - per
 quadrant E1

D5286 Removable unilateral partial denture - one piece resin (including

retentive/clasping materials, rests, and teeth) - per quadrant E1

Adjustment to Dentures
D5410 Adjust complete denture - maxillary E1

D5411 Adjust complete denture - mandibular E1

D5421 Adjust partial denture - maxillary E1

D5422 Adjust partial denture - mandibular E1

Repairs to Complete Dentures

D5511 Repair broken complete denture base, mandibular E1

D5512 Repair broken complete denture base, maxillary E1

D5520 Replace missing or broken teeth-complete denture (each tooth)

E1

Repairs to Partial Dentures

D5611 Repair resin partial denture base, mandibular E1

D5612 Repair resin partial denture base, maxillary E1

D5621 Repair cast partial framework, mandibular E1

D5622 Repair cast partial framework, maxillary E1

D5630 Repair or replace broken, retentive clasping materials - per tooth

E1
D5640 Replace broken teeth - per tooth E1

D5650 Add tooth to existing partial denture E1

D5660 Add clasp to existing partial denture - per tooth E1

D5670 Replace all teeth and acrylic on cast metal framework (maxillary)
E1
D5671 Replace all teeth and acrylic on cast metal framework (mandibular)
E1

Denture Rebase Procedures

D5710 Rebase complete maxillary denture E1

D5711 Rebase complete mandibular denture E1

D5720 Rebase maxillary partial denture E1

D5721 Rebase mandibular partial denture E1

 D5725 Rebase hybrid prosthesis E1

Replacing the base material connected to the framework.

Denture Reline Procedures

D5730 Reline complete maxillary denture (direct) E1

D5731 Reline lower complete mandibular denture (direct) E1

D5740 Reline maxillary partial denture (direct) E1

D5741 Reline mandibular partial denture (direct) E1

D5750 Reline complete maxillary denture (indirect) E1

D5751 Reline complete mandibular denture (indirect) E1

D5760 Reline maxillary partial denture (indirect) E1

D5761 Reline mandibular partial denture (indirect) E1

D5765 Soft liner for complete or partial removable denture – indirect E1

A discrete procedure provided when the dentist determines

placement of the soft liner is clinically indicated.

Interim Prosthesis
D5810 Interim complete denture (maxillary) E1

D5811 Interim complete denture (mandibular) E1

D5820 Interim partial denture (including retentive/clasping materials, rests,

and teeth), maxillary E1

D5821 Interim partial denture (including retentive/clasping materials, rests,

and teeth), mandibular E1

Other Removable Prosthetic Services

D5850 Tissue conditioning, maxillary E1

Treatment reline using materials designed to heal unhealthy ridges

prior to more definitive final restoration.
D5851 Tissue conditioning, mandibular E1

Treatment reline using materials designed to heal unhealthy ridges

prior to more definitive final restoration.
D5862 Precision attachment, by report E1

Each pair of components is one precision attachment. Describe the

type of attachment used.
D5863 Overdenture - complete maxillary E1
 D5864 Overdenture - partial maxillary E1

D5865 Overdenture - complete mandibular E1

D5866 Overdenture - partial mandibular E1

D5867 Replacement of replaceable part of semi-precision or precision

attachment, per attachment E1

D5875 Modification of removable prosthesis following implant surgery

E1
Attachment assemblies are reported using separate codes.
D5876 Add metal substructure to acrylic full denture (per arch) E1

None
D5899 Unspecified removable prosthodontic procedure, by report E1

Use for a procedure that is not adequately described by a code.

Describe procedure.

Maxillofacial Prosthetics
D5911 Facial moulage (sectional) S

A sectional facial moulage impression is a procedure used to record

the soft tissue contours of a portion of the face. Occasionally several
separate sectional impressions are made, then reassembled to
provide a full facial contour cast. The impression is utilized to create
a partial facial moulage and generally is not reusable.
D5912 Facial moulage (complete) S

Synonymous terminology: facial impression, face mask impression.

A complete facial moulage impression is a procedure used to record
the soft tissue contours of the whole face. The impression is utilized
to create a facial moulage and generally is not reusable.
D5913 Nasal prosthesis E1

Synonymous terminology: artificial nose. A removable prosthesis

attached to the skin, which artificially restores part or all of the nose.
Fabrication of a nasal prosthesis requires creation of an original
mold. Additional prostheses usually can be made from the same
mold, and assuming no further tissue changes occur, the same mold
can be utilized for extended periods of time. When a new prosthesis
is made from the existing mold, this procedure is termed a nasal
prosthesis replacement.
Cross Reference 21087
D5914 Auricular prosthesis E1
 Synonymous terminology: artificial ear, ear prosthesis. A removable
prosthesis, which artificially restores part or all of the natural ear.
Usually, replacement prostheses can be made from the original mold
if tissue bed changes have not occurred. Creation of an auricular
prosthesis requires fabrication of a mold, from which additional
prostheses usually can be made, as needed later (auricular
prosthesis, replacement).
Cross Reference 21086
D5915 Orbital prosthesis E1

A prosthesis, which artificially restores the eye, eyelids, and

adjacent hard and soft tissue, lost as a result of trauma or surgery.
Fabrication of an orbital prosthesis requires creation of an original
mold. Additional prostheses usually can be made from the same
mold, and assuming no further tissue changes occur, the same mold
can be utilized for extended periods of time. When a new prosthesis
is made from the existing mold, this procedure is termed an orbital
prosthesis replacement.
Cross Reference L8611
D5916 Ocular prosthesis E1

Synonymous terminology: artificial eye, glass eye. A prosthesis,

which artificially replaces an eye missing as a result of trauma,
surgery or congenital absence. The prosthesis does not replace
missing eyelids or adjacent skin, mucosa or muscle. Ocular
prostheses require semiannual or annual cleaning and polishing.
Also, occasional revisions to re-adapt the prosthesis to the tissue bed
may be necessary. Glass eyes are rarely made and cannot be re-
adapted.
Cross Reference V2623, V2629
D5919 Facial prosthesis E1

Synonymous terminology: prosthetic dressing. A removable

prosthesis, which artificially replaces a portion of the face, lost due
to surgery, trauma or congenital absence. Flexion of natural tissues
may preclude adaptation and movement of the prosthesis to match
the adjacent skin. Salivary leakage, when communicating with the
oral cavity, adversely affects retention.
Cross Reference 21088
D5922 Nasal septal prosthesis E1

Synonymous terminology: septal plug, septal button. Removable

prosthesis to occlude (obturate) a hole within the nasal septal wall.
 Adverse chemical degradation in this moist environment may
require frequent replacement. Silicone prostheses are occasionally
subject to fungal invasion.
Cross Reference 30220
D5923 Ocular prosthesis, interim E1

Synonymous terminology: eye shell, shell, ocular conformer,

conformer. A temporary replacement generally made of clear acrylic
resin for an eye lost due to surgery or trauma. No attempt is made to
re-establish aesthetics. Fabrication of an interim ocular prosthesis
generally implies subsequent fabrication of an aesthetic ocular
prosthesis.
Cross Reference 92330
D5924 Cranial prosthesis E1

Synonymous terminology: skull plate, cranioplasty prosthesis,

cranial implant. A biocompatible, permanently implanted
replacement of a portion of the skull bones; an artificial replacement
for a portion of the skull bone.
Cross Reference 62143
D5925 Facial augmentation implant prosthesis E1

Synonymous terminology: facial implant. An implantable

biocompatible material generally onlayed upon an existing bony
area beneath the skin tissue to fill in or collectively raise portions of
the overlaying facial skin tissues to create acceptable contours.
Although some forms of pre-made surgical implants are
commercially available, the facial augmentation is usually custom
made for surgical implantation for each individual patient due to the
irregular or extensive nature of the facial deficit.
Cross Reference 21208
D5926 Nasal prosthesis, replacement E1

Synonymous terminology: replacement nose. An artificial nose

produced from a previously made mold. A replacement prosthesis
does not require fabrication of a new mold. Generally, several
prostheses can be made from the same mold assuming no changes
occur in the tissue bed due to surgery or age related topographical
variations.
Cross Reference 21087
D5927 Auricular prosthesis, replacement E1

Synonymous terminology: replacement ear. An artificial ear

 produced from a previously made mold. A replacement prosthesis
does not require fabrication of a new mold. Generally, several
prostheses can be made from the same mold assuming no changes
occur in the tissue bed due to surgery or age related topographical
variations.
Cross Reference 21086
D5928 Orbital prosthesis, replacement E1

A replacement for a previously made orbital prosthesis. A

replacement prosthesis does not require fabrication of a new mold.
Generally, several prostheses can be made from the same mold
assuming no changes occur in the tissue bed due to surgery or age
related topographical variations.
Cross Reference 67550
D5929 Facial prosthesis, replacement E1

A replacement facial prosthesis made from the original mold. A

replacement prosthesis does not require fabrication of a new mold.
Generally, several prostheses can be made from the same mold
assuming no changes occur in the tissue bed due to further surgery
or age related topographical variations.
Cross Reference 21088
D5931 Obturator prosthesis, surgical E1

Synonymous terminology: obturator, surgical stayplate, immediate

temporary obturator. A temporary prosthesis inserted during or
immediately following surgical or traumatic loss of a portion or all
of one or both maxillary bones and contiguous alveolar structures
(e.g., gingival tissue, teeth). Frequent revisions of surgical
obturators are necessary during the ensuing healing phase
(approximately six months). Some dentists prefer to replace many or
all teeth removed by the surgical procedure in the surgical obturator,
while others do not replace any teeth. Further surgical revisions may
require fabrication of another surgical obturator (e.g., an initially
planned small defect may be revised and greatly enlarged after the
final pathology report indicates margins are not free of tumor).
Cross Reference 21079
D5932 Obturator prosthesis, definitive E1

Synonymous terminology: obturator. A prosthesis, which artificially

replaces part or all of the maxilla and associated teeth, lost due to
surgery, trauma or congenital defects. A definitive obturator is made
when it is deemed that further tissue changes or recurrence of tumor
 are unlikely and a more permanent prosthetic rehabilitation can be
achieved; it is intended for long-term use.
Cross Reference 21080
D5933 Obturator prosthesis, modification E1

Synonymous terminology: adjustment, denture adjustment,

temporary or office reline. Revision or alteration of an existing
obturator (surgical, interim, or definitive); possible modifications
include relief of the denture base due to tissue compression,
augmentation of the seal or peripheral areas to affect adequate
sealing or separation between the nasal and oral cavities.
Cross Reference 21080
D5934 Mandibular resection prosthesis with guide flange E1

Synonymous terminology: resection device, resection appliance. A

prosthesis which guides the remaining portion of the mandible, left
after a partial resection, into a more normal relationship with the
maxilla. This allows for some tooth-to-tooth or an improved tooth
contact. It may also artificially replace missing teeth and thereby
increase masticatory efficiency.
Cross Reference 21081
D5935 Mandibular resection prosthesis without guide flange E1

A prosthesis which helps guide the partially resected mandible to a

more normal relation with the maxilla allowing for increased tooth
contact. It does not have a flange or ramp, however, to assist in
directional closure. It may replace missing teeth and thereby
increase masticatory efficiency. Dentists who treat mandibulectomy
patients may prefer to replace some, all or none of the teeth in the
defect area. Frequently, the defect’s margins preclude even partial
replacement. Use of a guide (a mandibular resection prosthesis with
a guide flange) may not be possible due to anatomical limitations or
poor patient tolerance. Ramps, extended occlusal arrangements and
irregular occlusal positioning relative to the denture foundation
frequently preclude stability of the prostheses, and thus some
prostheses are poorly tolerated under such adverse circumstances.
Cross Reference 21081
D5936 Obturator/prosthesis, interim E1

Synonymous terminology: immediate postoperative obturator. A

prosthesis which is made following completion of the initial healing
after a surgical resection of a portion or all of one or both the
maxillae; frequently many or all teeth in the defect area are replaced
 by this prosthesis. This prosthesis replaces the surgical obturator,
which is usually inserted at, or immediately following the resection.
Generally, an interim obturator is made to facilitate closure of the
resultant defect after initial healing has been completed. Unlike the
surgical obturator, which usually is made prior to surgery and
frequently revised in the operating room during surgery, the interim
obturator is made when the defect margins are clearly defined and
further surgical revisions are not planned. It is a provisional
prosthesis, which may replace some or all lost teeth, and other lost
bone and soft tissue structures. Also, it frequently must be revised
(termed an obturator prosthesis modification) during subsequent
dental procedures (e.g., restorations, gingival surgery) as well as to
compensate for further tissue shrinkage before a definitive obturator
prosthesis is made.
Cross Reference 21079
D5937 Trismus appliance (not for tm treatment) E1

Synonymous terminology: occlusal device for mandibular trismus,

dynamic bite opener. A prosthesis, which assists the patient in
increasing their oral aperture width in order to eat as well as
maintain oral hygiene. Several versions and designs are possible, all
intending to ease the severe lack of oral opening experienced by
many patients immediately following extensive intraoral surgical
procedures.
D5951 Feeding aid E1

Synonymous terminology: feeding prosthesis. A prosthesis, which

maintains the right and left maxillary segments of an infant cleft
palate patient in their proper orientation until surgery is performed
to repair the cleft. It closes the oral-nasal cavity defect, thus
enhancing sucking and swallowing. Used on an interim basis, this
prosthesis achieves separation of the oral and nasal cavities in
infants born with wide clefts necessitating delayed closure. It is
eliminated if surgical closure can be affected or, alternatively, with
eruption of the deciduous dentition a pediatric speech aid may be
made to facilitate closure of the defect.
D5952 Speech aid prosthesis, pediatric E1

Synonymous terminology: nasopharyngeal obturator, speech

appliance, obturator, cleft palate appliance, prosthetic speech aid,
speech bulb. A temporary or interim prosthesis used to close a
defect in the hard and/or soft palate. It may replace tissue lost due to
 developmental or surgical alterations. It is necessary for the
production of intelligible speech. Normal lateral growth of the
palatal bones necessitates occasional replacement of this prosthesis.
Intermittent revisions of the obturator section can assist in
maintenance of palatalpharyngeal closure (termed a speech aid
prosthesis modification). Frequently, such prostheses are not
fabricated before the deciduous dentition is fully erupted since clasp
retention is often essential.
Cross Reference 21084
D5953 Speech aid prosthesis, adult E1

Synonymous terminology: prosthetic speech appliance, speech aid,

speech bulb. A definitive prosthesis, which can improve speech in
adult cleft palate patients either by obturating (sealing off) a palatal
cleft or fistula, or occasionally by assisting an incompetent soft
palate. Both mechanisms are necessary to achieve velopharyngeal
competency. Generally, this prosthesis is fabricated when no further
growth is anticipated and the objective is to achieve long-term use.
Hence, more precise materials and techniques are utilized.
Occasionally such procedures are accomplished in conjunction with
precision attachments in crown work undertaken on some or all
maxillary teeth to achieve improved aesthetics.
Cross Reference 21084
D5954 Palatal augmentation prosthesis E1

Synonymous terminology: superimposed prosthesis, maxillary

glossectomy prosthesis, maxillary speech prosthesis, palatal drop
prosthesis. A removable prosthesis which alters the hard and/or soft
palate’s topographical form adjacent to the tongue.
Cross Reference 21082
D5955 Palatal lift prosthesis, definitive E1

A prosthesis which elevates the soft palate superiorly and aids in

restoration of soft palate functions which may be lost due to an
acquired, congenital or developmental defect. A definitive palatal
lift is usually made for patients whose experience with an interim
palatal lift has been successful, especially if surgical alterations are
deemed unwarranted.
Cross Reference 21083
D5958 Palatal lift prosthesis, interim E1

Synonymous terminology: diagnostic palatal lift. A prosthesis which

elevates and assists in restoring soft palate function which may be
 lost due to clefting, surgery, trauma or unknown paralysis. It is
intended for interim use to determine its usefulness in achieving
palatalpharyngeal competency or enhance swallowing reflexes. This
prosthesis is intended for interim use as a diagnostic aid to assess
the level of possible improvement in speech intelligibility. Some
clinicians believe use of a palatal lift on an interim basis may
stimulate an otherwise flaccid soft palate to increase functional
activity, subsequently lessening its need.
Cross Reference 21083
D5959 Palatal lift prosthesis, modification E1

Synonymous terminology: revision of lift, adjustment. Alterations in

the adaptation, contour, form or function of an existing palatal lift
necessitated due to tissue impingement, lack of function, poor clasp
adaptation or the like.
Cross Reference 21083
D5960 Speech aid prosthesis, modification E1

Synonymous terminology: adjustment, repair, revision. Any revision

of a pediatric or adult speech aid not necessitating its replacement.
Frequently, revisions of the obturating section of any speech aid is
required to facilitate enhanced speech intelligibility. Such revisions
or repairs do not require complete remaking of the prosthesis, thus
extending its longevity.
Cross Reference 21084
D5982 Surgical stent E1

Synonymous terminology: periodontal stent, skin graft stent,

columellar stent. Stents are utilized to apply pressure to soft tissues
to facilitate healing and prevent cicatrization or collapse. A surgical
stent may be required in surgical and post-surgical revisions to
achieve close approximation of tissues. Usually such materials as
temporary or interim soft denture liners, gutta percha, or dental
modeling impression compound may be used.
Cross Reference 21085
D5983 Radiation carrier S

Synonymous terminology: radiotherapy prosthesis, carrier

prosthesis, radiation applicator, radium carrier, intracavity carrier,
intracavity applicator. A device used to administer radiation to
confined areas by means of capsules, beads or needles of radiation
emitting materials such as radium or cesium. Its function is to hold
the radiation source securely in the same location during the entire
 period of treatment. Radiation oncologists occasionally request
these devices to achieve close approximation and controlled
application of radiation to a tumor deemed amiable to eradication.
D5984 Radiation shield S

Synonymous terminology: radiation stent, tongue protector, lead

shield. An intraoral prosthesis designed to shield adjacent tissues
from radiation during orthovoltage treatment of malignant lesions of
the head and neck region.
D5985 Radiation cone locator S

Synonymous terminology: docking device, cone locator. A

prosthesis utilized to direct and reduplicate the path of radiation to
an oral tumor during a split course of irradiation.
D5986 Fluoride gel carrier E1

Synonymous terminology: fluoride applicator. A prosthesis, which

covers the teeth in either dental arch and is used to apply topical
fluoride in close proximity to tooth enamel and dentin for several
minutes daily.
D5987 Commissure splint S

Synonymous terminology: lip splint. A device placed between the

lips, which assists in achieving increased opening between the lips.
Use of such devices enhances opening where surgical, chemical or
electrical alterations of the lips has resulted in severe restriction or
contractures.
D5988 Surgical splint E1

Synonymous terminology: Gunning splint, modified Gunning splint,

labiolingual splint, fenestrated splint, Kingsley splint, cast metal
splint. Splints are designed to utilize existing teeth and/or alveolar
processes as points of anchorage to assist in stabilization and
immobilization of broken bones during healing. They are used to re-
establish, as much as possible, normal occlusal relationships during
the process of immobilization. Frequently, existing prostheses (e.g.,
a patient’s complete dentures) can be modified to serve as surgical
splints. Frequently, surgical splints have arch bars added to facilitate
intermaxillary fixation. Rubber elastics may be used to assist in this
process. Circummandibular eyelet hooks can be utilized for
enhanced stabilization with wiring to adjacent bone.
D5991 Vesicobullous disease medicament carrier E1

A custom fabricated carrier that covers the teeth and alveolar

mucosa, or alveolar mucosa alone, and is used to deliver
 prescription medicaments for treatment of immunologically
mediated vesiculobullous disease.
D5992 Adjust maxillofacial prosthetic appliance, by report E1

D5993 Maintenance and cleaning of a maxillofacial prosthesis (extra or

intraoral) other than required adjustments, by report E1

D5995 Periodontal medicament carrier with peripheral seal – laboratory

processed – maxillary
A custom fabricated, laboratory processed carrier for the maxillary
arch that covers the teeth and alveolar mucosa. Used as a vehicle to
deliver prescribed medicaments for sustained contact with the
gingiva, alveolar mucosa, and into the periodontal sulcus or pocket.
D5996 Periodontal medicament carrier with peripheral seal – laboratory
processed – mandibular
A custom fabricated, laboratory processed carrier for the mandibular
arch that covers the teeth and alveolar mucosa. Used as a vehicle to
deliver prescribed medicaments for sustained contact with the
gingiva, alveolar mucosa, and into the periodontal sulcus or pocket.
D5999 Unspecified maxillofacial prosthesis, by report E1

Used for procedure that is not adequately described by a code.

Describe procedure.

Implant Services (D6010-D6199)

D6010-D6199: FPD = fixed partial denture

Surgical Services
D6010 Surgical placement of implant body: endosteal implant E1

Cross Reference 21248

D6011 Surgical access to an implant body (second stage implant surgery)
E1
This procedure, also known as second stage implant surgery,
involves removal of tissue that covers the implant body so that a
fixture of any type can be placed, or an existing fixture be replaced
with another. Examples of fixtures include but are not limited to
healing caps, abutments shaped to help contour the gingival margins
or the final restorative prosthesis.
D6012 Surgical placement of interim implant body for transitional
prosthesis: endosteal implant E1

D6013 Surgical placement of mini implant E1

 D6040 Surgical placement: eposteal implant E1

An eposteal (subperiosteal) framework of a biocompatible material

designed and fabricated to fit on the surface of the bone of the
mandible or maxilla with permucosal extensions which provide
support and attachment of a prosthesis. This may be a complete arch
or unilateral appliance. Eposteal implants rest upon the bone and
under the periosteum.
Cross Reference 21245
D6050 Surgical placement: transosteal implant E1

A transosteal (transosseous) biocompatible device with threaded

posts penetrating both the superior and inferior cortical bone plates
of the mandibular symphysis and exiting through the permucosa
providing support and attachment for a dental prosthesis.
Transosteal implants are placed completely through the bone and
into the oral cavity from extraoral or intraoral.
Cross Reference 21244

Implant Supported Prosthetics

D6051 Interim abutment placement implant E1

A healing cap is not an interim abutment.

D6055 Connecting bar — implant supported or abutment supported E1

Utilized to stabilize and anchor a prosthesis.

D6056 Prefabricated abutment - includes modification and placement E1

Modification of a prefabricated abutment may be necessary.

D6057 Custom fabricated abutment - includes placement E1

Created by a laboratory process, specific for an individual

application.
D6058 Abutment supported porcelain/ceramic crown E1

A single crown restoration that is retained, supported and stabilized

by an abutment on an implant.
D6059 Abutment supported porcelain fused to metal crown (high noble
metal) E1

A single metal-ceramic crown restoration that is retained, supported

and stabilized by an abutment on an implant.
D6060 Abutment supported porcelain fused to metal crown (predominantly
base metal) E1

A single metal-ceramic crown restoration that is retained, supported

 and stabilized by an abutment on an implant.
D6061 Abutment supported porcelain fused to metal crown (noble metal)
E1
A single metal-ceramic crown restoration that is retained,
supported and stabilized by an abutment on an implant.
D6062 Abutment supported cast metal crown (high noble metal) E1

A single cast metal crown restoration that is retained, supported and

stabilized by an abutment on an implant.
D6063 Abutment supported cast metal crown (predominantly base metal)
A single cast metal crown restoration that is retained, supported E1
and stabilized by an abutment on an implant.
D6064 Abutment supported cast metal crown (noble metal) E1

A single cast metal crown restoration that is retained, supported and

stabilized by an abutment on an implant.
D6065 Implant supported porcelain/ceramic crown E1

A single crown restoration that is retained, supported and stabilized

by an implant.
D6066 Implant supported crown - porcelain fused to high noble alloys
E1
A single metal-ceramic crown restoration that is retained,
supported and stabilized by an implant.
D6067 Implant supported crown - high noble alloys E1

A single cast metal or milled crown restoration that is retained,

supported and stabilized by an implant.
D6068 Abutment supported retainer for porcelain/ceramic FPD E1

A ceramic retainer for a fixed partial denture that gains retention,

support and stability from an abutment on an implant.
D6069 Abutment supported retainer for porcelain fused to metal FPD (high
noble metal) E1

A metal-ceramic retainer for a fixed partial denture that gains

retention, support and stability from an abutment on an implant.
D6070 Abutment supported retainer for porcelain fused to metal FPD
(predominantly base metal) E1

A metal-ceramic retainer for a fixed partial denture that gains

retention, support and stability from an abutment on an implant.
D6071 Abutment supported retainer for porcelain fused to metal FPD
(noble metal) E1

A metal-ceramic retainer for a fixed partial denture that gains

retention, support and stability from an abutment on an implant.
D6072 Abutment supported retainer for cast metal FPD (high noble metal)
E1
A cast metal retainer for a fixed partial denture that gains retention,
support and stability from an abutment on an implant.
D6073 Abutment supported retainer for cast metal FPD (predominantly
base metal) E1

A cast metal retainer for a fixed partial denture that gains retention,
support and stability from an abutment on an implant.
D6074 Abutment supported retainer for cast metal FPD (noble metal) E1

A cast metal retainer for a fixed partial denture that gains retention,
support and stability from an abutment on an implant.
D6075 Implant supported retainer for ceramic FPD E1

A ceramic retainer for a fixed partial denture that gains retention,

support and stability from an implant.
D6076 Implant supported retainer for FPD - porcelain fused to high noble
alloys E1

A metal-ceramic retainer for a fixed partial denture that gains

retention, support and stability from an implant.
D6077 Implant supported retainer for metal FPD - high noble alloys E1

A cast metal retainer for a fixed partial denture that gains retention,
support and stability from an implant.
Other Implant Services
D6080 Implant maintenance procedures when prostheses are removed and
reinserted, including cleansing of prostheses and abutments E1

This procedure includes active debriding of the implant(s) and

examination of all aspects of the implant system(s), including the
occlusion and stability of the superstructure. The patient is also
instructed in thorough daily cleansing of the implant(s). This is not a
per implant code, and is indicated for implant supported fixed
prostheses.
D6081 Scaling and debridement in the presence of inflammation or
mucositis of a single implant, including cleaning of the implant
surfaces, without flap entry and closure E1

This procedure is not performed in conjunction with D1110, D4910,

or D4346.
D6082 Implant supported crown - porcelain fused to predominantly base
alloys E1

D6083 Implant supported crown - porcelain fused to noble alloys E1

D6084 Implant supported crown - porcelain fused to titanium and titanium

alloys E1

D6085 Interim implant crown E1

Placed when a period of healing is necessary prior to fabrication and

placement of definitive prosthetic.
D6086 Implant supported crown - predominantly base alloys E1

D6087 Implant supported crown - noble alloys E1

D6088 Implant supported crown - titanium and titanium alloys E1

D6090 Repair implant supported prosthesis by report E1

This procedure involves the repair or replacement of any part of the

implant supported prosthesis.
Cross Reference 21299
D6091 Replacement of replaceable part of semi-precision or precision
attachment of implant/abutment supported prosthesis, per
attachment E1

D6092 Re-cement or re-bond implant/abutment supported crown E1

D6093 Re-cement or re-bond implant/abutment supported fixed partial

denture E1

D6094 Abutment supported crown - titanium and titanium alloys E1

 A single crown restoration that is retained, supported and stabilized
by an abutment on an implant. May be cast or milled.
D6095 Repair implant abutment, by report E1

This procedure involves the repair or replacement of any part of the

implant abutment.
Cross Reference 21299
D6096 Remove broken implant retaining screw E1

D6097 Abutment supported crown - porcelain fused to titanium and

titanium alloys E1

A single metal-ceramic crown restoration that is retained, supported,

and stabilized by an abutment on an implant.
D6098 Implant supported retainer - porcelain fused to predominantly base
alloys E1

A metal-ceramic retainer for a fixed partial denture that gains

retention, support, and stability from an implant.
D6099 Implant supported retainer for FPD - porcelain fused to noble alloys
E1
A metal-ceramic retainer for a fixed partial denture that gains
retention, support, and stability from an implant.

Surgical Services
D6100 Surgical removal, of implant body E1

Cross Reference 21299

D6101 Debridement of a peri-implant defect or defects surrounding a single
implant, and surface cleaning of exposed implant surfaces, including
flap entry and closure E1

D6102 Debridement and osseous contouring of a peri-implant defect or

defects surrounding a single implant and includes surface cleaning
of the exposed implant surfaces and flap entry and closure E1

D6103 Bone graft for repair of peri-implant defect - does not include flap
entry and closure E1

Placement of a barrier membrane or biologic materials to aid in

osseous regeneration, are reported separately.
D6104 Bone graft at time of implant placement E1

Placement of a barrier membrane, or biologic materials to aid in

osseous regeneration are reported separately.
▶ D6105 Removal of implant body not requiring bone removal or flap
elevation B
 ▶ D6106 Guided tissue regeneration - resorbable barrier, per implant B

This procedure does not include flap entry and closure, or, when
indicated, wound debridement, osseous contouring, bone
replacement grafts, and placement of biologic materials to aid in
osseous regeneration. This procedure is used for peri-implant
defects and during implant placement.
▶ D6107 Guided tissue regeneration - nonresorbable barrier, per implant B

This procedure does not include flap entry and closure, or, when
indicated, wound debridement, osseous contouring, bone
replacement grafts, and placement of biologic materials to aid in
osseous regeneration. This procedure is used for peri-implant
defects and during implant placement.

Implant Supported Prosthetics

D6110 Implant/abutment supported removable denture for edentulous arch
- maxillary E1

D6111 Implant/abutment supported removable denture for edentulous arch

- mandibular E1

D6112 Implant/abutment supported removable denture for partially

edentulous arch - maxillary E1

D6113 Implant/abutment supported removable denture for partially

edentulous arch - mandibular E1

D6114 Implant/abutment supported fixed denture for edentulous arch -

maxillary E1

D6115 Implant/abutment supported fixed denture for edentulous arch -

mandibular E1

D6116 Implant/abutment supported fixed denture for partially edentulous

arch - maxillary E1

D6117 Implant/abutment supported fixed denture for partially edentulous

arch - mandibular E1

D6118 Implant/abutment supported interim fixed denture for edentulous

arch mandibular E1

Used when a period of healing is necessary prior to fabrication and

placement of a permanent prosthetic.
D6119 Implant/abutment supported interim fixed denture for edentulous
arch maxillary E1

Used when a period of healing is necessary prior to fabrication and

placement of a permanent prosthetic.
 D6120 Implant supported retainer - porcelain fused to titanium and titanium
alloys E1

A metal-ceramic retainer for a fixed partial denture that gains

retention, support, and stability from an implant.
D6121 Implant supported retainer for metal FPD - predominantly base
alloys E1

A metal-ceramic retainer for a fixed partial denture that gains

retention, support, and stability from an implant.
D6122 Implant supported retainer for metal FPD - noble alloys E1

A metal retainer for a fixed partial denture that gains retention,

support, and stability from an implant.
D6123 Implant supported retainer for metal FPD - titanium and titanum
alloys E1

A metal retainer for a fixed partial denture that gains retention,

support, and stability from an implant.
D6190 Radiographic/surgical implant index, by report E1

An appliance, designed to relate osteotomy or fixture position to

existing anatomic structures, to be utilized during radiographic
exposure for treatment planning and/or during osteotomy creation
for fixture installation.
D6191 Semi-precision abutment – placement
This procedure is the initial placement, or replacement, of a semi-
precision abutment on the implant body.
D6192 Semi-precision attachment – placement
This procedure involves the luting of the initial, or replacement,
semiprecision attachment to the removable prosthesis.
D6194 Abutment supported retainer crown for FPD – titanium and titanium
alloys E1

A retainer for a fixed partial denture that gains retention, support

and stability from an abutment on an implant. May be cast or milled.
D6195 Abutment supported retainer - porcelain fused to titanium and
titanium alloys E1

A metal retainer for a fixed partial denture that gains retention,

support, and stability from an implant.
▶ D6197 Replacement of restorative material used to close an access opening
of a screw-retained implant supported prosthesis, per implant B
 D6198 Remove interim implant component E1

Removal of implant component (e.g., interim abutment; provisional

implant crown) originally placed for a specific clinical purpose and
period of time determined by the dentist.

None
D6199 Unspecified implant procedure, by report E1

Use for procedure that is not adequately described by a code.

Describe procedure.
Cross Reference 21299

Prosthodontics, fixed (D6205-D6999)

Fixed Partial Denture Pontics
D6205 Pontic - indirect resin based composite E1

Not to be used as a temporary or provisional prosthesis.

D6210 Pontic - cast high noble metal E1

D6211 Pontic - cast predominantly base metal E1

D6212 Pontic - cast noble metal E1

D6214 Pontic - titanium and titanium alloys E1

D6240 Pontic - porcelain fused to high noble metal E1

D6241 Pontic - porcelain fused to predominantly base metal E1

D6242 Pontic - porcelain fused to noble metal E1

IOM: 100-02, 15, 150

D6243 Pontic - porcelain fused to titanium and titanium alloys E1

D6245 Pontic - porcelain/ceramic E1

D6250 Pontic - resin with high noble metal E1

D6251 Pontic - resin with predominantly base metal E1

D6252 Pontic - resin with noble metal E1

D6253 Interim pontic - further treatment or completion of diagnosis

necessary prior to final impression E1

Not to be used as a temporary pontic for routine prosthetic

restoration.

Fixed Partial Denture Retainers – Inlays/Onlays

D6545 Retainer - cast metal for resin bonded fixed prosthesis E1
 D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis E1

D6549 Retainer - for resin bonded fixed prosthesis E1

D6600 Retainer inlay - porcelain/ceramic, two surfaces E1

D6601 Retainer inlay - porcelain/ceramic, three or more surfaces E1

D6602 Retainer inlay - cast high noble metal, two surfaces E1

D6603 Retainer inlay - cast high noble metal, three or more surfaces E1

D6604 Retainer inlay - cast predominantly base metal, two surfaces E1

D6605 Retainer inlay - cast predominantly base metal, three or more

surfaces E1

D6606 Retainer inlay - cast noble metal, two surfaces E1

D6607 Retainer inlay - cast noble metal, three or more surfaces E1

D6608 Retainer onlay - porcelain/ceramic, two surfaces E1

D6609 Retainer onlay - porcelain/ceramic, three or more surfaces E1

D6610 Retainer onlay - cast high noble metal, two surfaces E1

D6611 Retainer onlay - cast high noble metal, three or more surfaces E1

D6612 Retainer onlay - cast predominantly base metal, two surfaces E1

D6613 Retainer onlay - cast predominantly base metal, three or more

surfaces E1

D6614 Retainer onlay - cast noble metal, two surfaces E1

D6615 Retainer onlay - cast noble metal, three or more surfaces E1

D6624 Retainer inlay - titanium E1

D6634 Retainer onlay - titanium E1

Fixed Partial Denture Retainers – Crowns

D6710 Retainer crown - indirect resin based composite E1

Not to be used as a temporary or provisional prosthesis.

D6720 Retainer crown - resin with high noble metal E1

D6721 Retainer crown - resin with predominantly base metal E1

D6722 Retainer crown - resin with noble metal E1

D6740 Retainer crown - porcelain/ceramic E1

D6750 Retainer crown - porcelain fused to high noble metal E1

D6751 Retainer crown - porcelain fused to predominantly base metal E1

D6752 Retainer crown - porcelain fused to noble metal E1

D6753 Retainer crown - porcelain fused to titanium and titanium alloys E1

 D6780 Retainer crown - 3/4 cast high noble metal E1

D6781 Retainer crown - 3/4 cast predominantly based metal E1

D6782 Retainer crown - 3/4 cast noble metal E1

D6783 Retainer crown - 3/4 porcelain/ceramic E1

D6784 Retainer crown 3/4 - titanium and titanium alloys E1

D6790 Retainer crown - full cast high noble metal E1

D6791 Retainer crown - full cast predominantly base metal E1

D6792 Retainer crown - full cast noble metal E1

D6793 Interim retainer crown - further treatment or completion of

diagnosis necessary prior to final impression E1

Not to be used as a temporary retainer crown for routine prosthetic

restoration.
D6794 Retainer crown - titanium and titanium alloys E1

Other Fixed Partial Denture Services

D6920 Connector bar S

A device attached to fixed partial denture retainer or coping which

serves to stabilize and anchor a removable overdenture prosthesis.
D6930 Re-cement or re-bond fixed partial denture E1

D6940 Stress breaker E1

A non-rigid connector.
D6950 Precision attachment E1

A pair of components constitutes one precision attachment that is

separate from the prosthesis.
D6980 Bridge repair necessitated by restorative material failure E1

D6985 Pediatric partial denture, fixed E1

This prosthesis is used primarily for aesthetic purposes.

None
D6999 Unspecified fixed prosthodontic procedure, by report E1

Used for procedure that is not adequately described by a code.

Describe procedure.

Oral and Maxillofacial Surgery (D7111-D7999)

Extractions (Includes Local Anesthesia, Suturing, If Needed, and Routine
Postoperative Care)
D7111 Extraction, coronal remnants - primary tooth S

Removal of soft tissue-retained coronal remnants.

D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps
removal) S

Includes removal of tooth structure, minor smoothing of socket

bone, and closure, as necessary.
D7210 Extraction, erupted tooth requiring removal of bone and/or
sectioning of tooth, and including elevation of mucoperiosteal flap if
indicated S

Includes related cutting of gingiva and bone, removal of tooth

structure, minor smoothing of socket bone and closure.
D7220 Removal of impacted tooth - soft tissue S

Occlusal surface of tooth covered by soft tissue; requires

mucoperiosteal flap elevation.
D7230 Removal of impacted tooth - partially bony S

Part of crown covered by bone; requires mucoperiosteal flap

elevation and bone removal.
D7240 Removal of impacted tooth - completely bony S

Most or all of crown covered by bone; requires mucoperiosteal flap

elevation and bone removal.
D7241 Removal of impacted tooth - completely bony, with unusual surgical
complications S

Most or all of crown covered by bone; unusually difficult or

complicated due to factors such as nerve dissection required,
separate closure of maxillary sinus required or aberrant tooth
position.
D7250 Removal of residual tooth roots (cutting procedure) S

Includes cutting of soft tissue and bone, removal of tooth structure,

and closure.
D7251 Coronectomy — intentional partial tooth removal, impacted teeth
only E1

Intentional partial tooth removal is performed when a neurovascular

complication is likely if the entire impacted tooth is removed.

Other Surgical Procedures

D7260 Oroantral fistula closure S

Excision of fistulous tract between maxillary sinus and oral cavity

and closure by advancement flap.
D7261 Primary closure of a sinus perforation S

Subsequent to surgical removal of tooth, exposure of sinus requiring

repair, or immediate closure of oroantral or oralnasal
communication in absence of fistulous tract.
D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or
displaced tooth E1

Includes splinting and/or stabilization.

D7272 Tooth transplantation (includes reimplantation from one site to
another and splinting and/or stabilization) E1

D7280 Exposure of an unerupted tooth E1

An incision is made and the tissue is reflected and bone removed as

necessary to expose the crown of an impacted tooth not intended to
be extracted.
D7282 Mobilization of erupted or malpositioned tooth to aid eruption E1

To move/luxate teeth to eliminate ankylosis; not in conjunction with

an extraction.
D7283 Placement of device to facilitate eruption of impacted tooth B

Placement of an orthodontic bracket, band or other device on an

unerupted tooth, after its exposure, to aid in its eruption. Report the
surgical exposure separately using D7280.
D7285 Incisional biopsy of oral tissue - hard (bone, tooth) E1

For partial removal of specimen only. This procedure involves

biopsy of osseous lesions and is not used for
apicoectomy/periradicular surgery. This procedure does not entail an
excision.
Cross Reference 20220, 20225, 20240, 20245
D7286 Incisional biopsy of oral tissue - soft E1

For partial removal of an architecturally intact specimen only. This

procedure is not used at the same time as codes for
apicoectomy/periradicular curettage. This procedure does not entail
an excision.
Cross Reference 40808
D7287 Exfoliative cytological sample collection E1

For collection of non-transepithelial cytology sample via mild

 scraping of the oral mucosa.
D7288 Brush biopsy - transepithelial sample collection B

For collection of oral disaggregated transepithelial cells via

rotational brushing of the oral mucosa.
D7290 Surgical repositioning of teeth E1

Grafting procedure(s) is/are additional.

D7291 Transseptal fiberotomy/supra-crestal fiberotomy, by report S

The supraosseous connective tissue attachment is surgically severed

around the involved teeth. Where there are adjacent teeth, the
transseptal fiberotomy of a single tooth will involve a minimum of
three teeth. Since the incisions are within the gingival sulcus and
tissue and the root surface is not instrumented, this procedure heals
by the reunion of connective tissue with the root surface on which
viable periodontal tissue is present (reattachment).
D7292 Placement of temporary anchorage device [screw retained plate]
requiring flap E1

D7293 Placement of temporary anchorage device requiring flap E1

D7294 Placement of temporary anchorage device without flap E1

D7295 Harvest of bone for use in autogenous grafting procedure E1

Reported in addition to those autogenous graft placement

procedures that do not include harvesting of bone.
D7296 Corticotomy one to three teeth or tooth spaces, per quadrant E1

This procedure involves creating multiple cuts, perforations, or

removal of cortical, alveolar or basal bone of the jaw for the purpose
of facilitating orthodontic repositioning of the dentition. This
procedure includes flap entry and closure. Graft material and
membrane, if used, should be reported separately.
D7297 Corticotomy four or more teeth or tooth spaces, per quadrant E1

This procedure involves creating multiple cuts, perforations, or

removal of cortical, alveolar or basal bone of the jaw for the purpose
of facilitating orthodontic repositioning of the dentition. This
procedure includes flap entry and closure. Graft material and
membrane, if used, should be reported separately.
D7298 Removal of temporary anchorage device [screw retained plate],
requiring flap E1

D7299 Removal of temporary anchorage device, requiring flap E1

D7300 Removal of temporary anchorage device without flap E1

Alveoloplasty – Preparation of Ridge
D7310 Alveoloplasty in conjunction with extractions - four or more teeth or
tooth spaces, per quadrant E1

The alveoloplasty is distinct (separate procedure) from extractions.

Usually in preparation for a prosthesis or other treatments such as
radiation therapy and transplant surgery.
Cross Reference 41874
D7311 Alveoloplasty in conjunction with extractions - one to three teeth or
tooth spaces, per quadrant E1

The alveoloplasty is distinct (separate procedure) from extractions.

Usually in preparation for a prosthesis or other treatments such as
radiation therapy and transplant surgery.
D7320 Alveoloplasty not in conjunction with extractions - four or more
teeth or tooth spaces, per quadrant E1

No extractions performed in an edentulous area. See D7310 if teeth

are being extracted concurrently with the alveoloplasty. Usually in
preparation for a prosthesis or other treatments such as radiation
therapy and transplant surgery.
Cross Reference 41870
D7321 Alveoloplasty not in conjunction with extractions - one to three
teeth or tooth spaces, per quadrant B

No extractions performed in an edentulous area. See D7311 if teeth

are being extracted concurrently with the alveoloplasty. Usually in
preparation for a prosthesis or other treatments such as radiation
therapy and transplant surgery.

Vestibuloplasty
D7340 Vestibuloplasty - ridge extension (second epithelialization) E1

Cross Reference 40840, 40842, 40843, 40844

D7350 Vestibuloplasty - ridge extension (including soft tissue grafts,
muscle reattachments, revision of soft tissue attachment, and
management of hypertrophied and hyperplastic tissue) E1

Cross Reference 40845

Excision of Soft Tissue Lesions

D7410 Excision of benign lesion up to 1.25 cm E1
 D7411 Excision of benign lesion greater than 1.25 cm E1

D7412 Excision of benign lesion, complicated E1

Requires extensive undermining with advancement or rotational flap

closure.
D7413 Excision of malignant lesion up to 1.25 cm E1

D7414 Excision of malignant lesion greater than 1.25 cm E1

D7415 Excision of malignant lesion, complicated E1

Requires extensive undermining with advancement or rotational flap

closure.

Excision of Intra-Osseous Lesions

D7440 Excision of malignant tumor - lesion diameter up to 1.25 cm E1

D7441 Excision of malignant tumor - lesion diameter greater than 1.25 cm

E1
D7450 Removal of benign odontogenic cyst or tumor - lesion diameter up
to 1.25 cm E1

D7451 Removal of benign odontogenic cyst or tumor - lesion diameter

greater than 1.25 cm E1

D7460 Removal of benign nonodontogenic cyst or tumor - lesion diameter

up to 1.25 cm E1

D7461 Removal of benign nonodontogenic cyst or tumor - lesion diameter

greater than 1.25 cm E1

Excision of Soft Tissue Lesions

D7465 Destruction of lesion(s) by physical or chemical methods, by report
E1
Examples include using cryo, laser or electro surgery.
Cross Reference 41850

Excision of Bone Tissue

D7471 Removal of lateral exostosis (maxilla or mandible) E1

Cross Reference 21031, 21032

D7472 Removal of torus palatinus E1

D7473 Removal of torus mandibularis E1

D7485 Reduction of osseous tuberosity E1

 D7490 Radical resection of maxilla or mandible E1

Partial resection of maxilla or mandible; removal of lesion and

defect with margin of normal appearing bone. Reconstruction and
bone grafts should be reported separately.
Cross Reference 21095

Surgical Incision
▶ D7509 Marsupialization of odontogenic cyst B

Surgical decompression of a large cystic lesion by creating a long-

term open pocket or pouch.
D7510 Incision and drainage of abscess - intraoral soft tissue E1

Involves incision through mucosa, including periodontal origins.

Cross Reference 41800
D7511 Incision and drainage of abscess - intraoral soft tissue - complicated
(includes drainage of multiple fascial spaces) B

Incision is made intraorally and dissection is extended into adjacent

fascial space(s) to provide adequate drainage of abscess/cellulitis.
D7520 Incision and drainage of abscess - extraoral soft tissue E1

Involves incision through skin.

Cross Reference 41800
D7521 Incision and drainage of abscess - extraoral soft tissue - complicated
(includes drainage of multiple fascial spaces) B

Incision is made extraorally and dissection is extended into adjacent

fascial space(s) to provide adequate drainage of abscess/cellulitis.
D7530 Removal of foreign body from mucosa, skin, or subcutaneous
alveolar tissue E1

Cross Reference 41805, 41828

D7540 Removal of reaction-producing foreign bodies, musculoskeletal
system E1

May include, but is not limited to, removal of splinters, pieces of

wire, etc., from muscle and/or bone.
Cross Reference 20520, 41800, 41806
D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone
Removal of loose or sloughed-off dead bone caused by infection E1
or reduced blood supply.
Cross Reference 20999
 D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body
E1
Cross Reference 31020

Treatment of Closed Fractures

D7610 Maxilla - open reduction (teeth immobilized, if present) E1

Teeth may be wired, banded or splinted together to prevent

movement. Incision required for interosseous fixation.
D7620 Maxilla - closed reduction (teeth immobilized if present) E1

No incision required to reduce fracture. See D7610 if interosseous

fixation is applied.
D7630 Mandible - open reduction (teeth immobilized, if present) E1

Teeth may be wired, banded or splinted together to prevent

movement. Incision required to reduce fracture.
D7640 Mandible - closed reduction (teeth immobilized if present) E1

No incision required to reduce fracture. See D7630 if interosseous

fixation is applied.
D7650 Malar and/or zygomatic arch - open reduction E1

D7660 Malar and/or zygomatic arch - closed reduction E1

D7670 Alveolus - closed reduction, may include stabilization of teeth E1

Teeth may be wired, banded or splinted together to prevent

movement.
D7671 Alveolus - open reduction, may include stabilization of teeth E1

Teeth may be wired, banded or splinted together to prevent

movement.
D7680 Facial bones - complicated reduction with fixation and multiple
surgical approaches E1

Facial bones include upper and lower jaw, cheek, and bones around
eyes, nose, and ears.

Treatment of Open Fractures

D7710 Maxilla - open reduction E1

Incision required to reduce fracture.

Cross Reference 21346
D7720 Maxilla - closed reduction E1

Cross Reference 21345

 D7730 Mandible - open reduction E1

Incision required to reduce fracture.

Cross Reference 21461, 21462
D7740 Mandible - closed reduction E1

Cross Reference 21455

D7750 Malar and/or zygomatic arch - open reduction E1

Incision required to reduce fracture.

Cross Reference 21360, 21365
D7760 Malar and/or zygomatic arch - closed reduction E1

Cross Reference 21355

D7770 Alveolus - open reduction stabilization of teeth E1

Fractured bone(s) are exposed to mouth or outside the face. Incision

required to reduce fracture.
Cross Reference 21422
D7771 Alveolus, closed reduction stabilization of teeth E1

Fractured bone(s) are exposed to mouth or outside the face.

D7780 Facial bones - complicated reduction with fixation and multiple
approaches E1

Incision required to reduce fracture. Facial bones include upper and

lower jaw, cheek, and bones around eyes, nose, and ears.
Cross Reference 21433, 21435

Reduction of Dislocation and Management of Other Temporomandibular Joint

Dysfunction
D7810 Open reduction of dislocation E1

Access to TMJ via surgical opening.

Cross Reference 21490
D7820 Closed reduction of dislocation E1

Joint manipulated into place; no surgical exposure.

Cross Reference 21480
D7830 Manipulation under anesthesia E1

Usually done under general anesthesia or intravenous sedation.

Cross Reference 00190
D7840 Condylectomy E1

Removal of all or portion of the mandibular condyle (separate

 procedure).
Cross Reference 21050
D7850 Surgical discectomy, with/without implant E1

Excision of the intra-articular disc of a joint.

Cross Reference 21060
D7852 Disc repair E1

Repositioning and/or sculpting of disc; repair of perforated posterior

attachment.
Cross Reference 21299
D7854 Synovectomy E1

Excision of a portion or all of the synovial membrane of a joint.

Cross Reference 21299
D7856 Myotomy E1

Cutting of muscle for therapeutic purposes (separate procedure).

Cross Reference 21299
D7858 Joint reconstruction E1

Reconstruction of osseous components including or excluding soft

tissues of the joint with autogenous, homologous, or alloplastic
materials.
Cross Reference 21242, 21243
D7860 Arthrotomy E1

Cutting into joint (separate procedure).

D7865 Arthroplasty E1

Reduction of osseous components of the joint to create a

pseudoarthrosis or eliminate an irregular remodeling pattern
(osteophytes).
Cross Reference 21240
D7870 Arthrocentesis E1

Withdrawal of fluid from a joint space by aspiration.

Cross Reference 21060
D7871 Non-arthroscopic lysis and lavage E1

Inflow and outflow catheters are placed into the joint space. The
joint is lavaged and manipulated as indicated in an effort to release
minor adhesions and synovial vacuum phenomenon as well as to
remove inflammation products from the joint space.
D7872 Arthroscopy - diagnosis, with or without biopsy E1
 Cross Reference 29800
D7873 Arthroscopy: lavage and lysis of adhesions E1

Removal of adhesions using the arthroscope and lavage of the joint

cavities.
Cross Reference 29804
D7874 Arthroscopy: disc repositioning and stabilization E1

Repositioning and stabilization of disc using arthroscopic

techniques.
Cross Reference 29804
D7875 Arthroscopy: synovectomy E1

Removal of inflamed and hyperplastic synovium (partial/complete)

via an arthroscopic technique.
Cross Reference 29804
D7876 Arthroscopy: discectomy E1

Removal of disc and remodeled posterior attachment via the

arthroscope.
Cross Reference 29804
D7877 Arthroscopy: debridement E1

Removal of pathologic hard and/or soft tissue using the arthroscope.

Cross Reference 29804
D7880 Occlusal orthotic device, by report E1

Presently includes splints provided for treatment of

temporomandibular joint dysfunction.
Cross Reference 21499
D7881 Occlusal orthotic device adjustment E1

D7899 Unspecified TMD therapy, by report E1

Used for procedure that is not adequately described by a code.

Describe procedure.
Cross Reference 21499

Repair of Traumatic Wounds

D7910 Suture of recent small wounds up to 5 cm E1

Cross Reference 12011, 12013

Complicated Suturing (Reconstruction Requiring Delicate Handling of Tissue

and Wide Undermining for Meticulous Closure)
 D7911 Complicated suture - up to 5 cm E1

Cross Reference 12051, 12052

D7912 Complicated suture - greater than 5 cm E1

Cross Reference 13132

Other Repair Procedures

D7920 Skin graft (identify defect covered, location, and type of graft) E1

D7921 Collection and application of autologous blood concentrate product

E1
D7922 Placement of intra-socket biological dressing to aid in hemostasis or
clot stabilization, per site E1

This procedure can be performed at time and/or after extraction to

aid in hemostasis. The socket is packed with a hemostatic agent to
aid in hemostasis and or clot stabilization.
D7940 Osteoplasty - for orthognathic deformities S

Reconstruction of jaws for correction of congenital, developmental

or acquired traumatic or surgical deformity.
D7941 Osteotomy - mandibular rami E1

Cross Reference 21193, 21195, 21196

D7943 Osteotomy - mandibular rami with bone graft; includes obtaining
the graft E1

Cross Reference 21194

D7944 Osteotomy - segmented or subapical E1

Report by range of tooth numbers within segment.

Cross Reference 21198, 21206
D7945 Osteotomy - body of mandible E1

Sectioning of lower jaw. This includes exposure, bone cut, fixation,

routine wound closure and normal postoperative follow-up care.
Cross Reference 21193, 21194, 21195, 21196
D7946 LeFort I (maxilla - total) E1

Sectioning of the upper jaw. This includes exposure, bone cuts,

downfracture, repositioning, fixation, routine wound closure and
normal post-operative follow-up care.
Cross Reference 21147
D7947 LeFort I (maxilla - segmented) E1

When reporting a surgically assisted palatal expansion without

 downfracture, this code would entail a reduced service and should
be “by report.”
Cross Reference 21145, 21146
D7948 LeFort II or LeFort III (osteoplasty of facial bones for midface
hypoplasia or retrusion) - without bone graft E1

Sectioning of upper jaw. This includes exposure, bone cuts,

downfracture, segmentation of maxilla, repositioning, fixation,
routine wound closure and normal post-operative follow-up care.
Cross Reference 21150
D7949 LeFort II or LeFort III - with bone graft E1

Includes obtaining autografts.

D7950 Osseous, osteoperiosteal, or cartilage graft of the mandible or
maxilla - autogenous or nonautogenous, by report E1

This procedure is for ridge augmentation or reconstruction to

increase height, width and/or volume of residual alveolar ridge. It
includes obtaining graft material. Placement of a barrier membrane,
if used, should be reported separately.
Cross Reference 21247
D7951 Sinus augmentation with bone or bone substitutes E1

The augmentation of the sinus cavity to increase alveolar height for

reconstruction of edentulous portions of the maxilla. This procedure
is performed via a lateral open approach. This includes obtaining the
bone or bone substitutes. Placement of a barrier membrane if used
should be reported separately.
D7952 Sinus augmentation via a vertical approach E1

The augmentation of the sinus to increase alveolar height by vertical

access through the ridge crest by raising the floor of the sinus and
grafting as necessary. This includes obtaining the bone or bone
substitutes.
D7953 Bone replacement graft for ridge preservation - per site E1

Graft is placed in an extraction or implant removal site at the time of

the extraction or removal to preserve ridge integrity (e.g., clinically
indicated in preparation for implant reconstruction or where alveolar
contour is critical to planned prosthetic reconstruction). Does not
include obtaining graft material. Membrane, if used should be
reported separately.
D7955 Repair of maxillofacial soft and/or hard tissue defect E1

Reconstruction of surgical, traumatic, or congenital defects of the

 facial bones, including the mandible, may utilize graft materials in
conjunction with soft tissue procedures to repair and restore the
facial bones to form and function. This does not include obtaining
the graft and these procedures may require multiple surgical
approaches. This procedure does not include edentulous maxilla and
mandibular reconstruction for prosthetic considerations.
Cross Reference 21299
▶ D7956 Guided tissue regeneration, edentulous area - resorbable barrier, per
site B

This procedure does not include flap entry and closure, or, when
indicated, wound debridement, osseous contouring, bone
replacement grafts, and placement of biologic materials to aid in
osseous regeneration. This procedure may be used for ridge
augmentation, sinus lift procedures, and after tooth extraction.
▶ D7957 Guided tissue regeneration, edentulous area - non-resorbable barrier,
per site B

This procedure does not include flap entry and closure, or, when
indicated, wound debridement, osseous contouring, bone
replacement grafts, and placement of biologic materials to aid in
osseous regeneration. This procedure may be used for ridge
augmentation, sinus lift procedures, and after tooth extraction.
D7961 Buccal / labial frenectomy (frenulectomy)
D7962 Lingual frenectomy (frenulectomy)
D7963 Frenuloplasty E1

Excision of frenum with accompanying excision or repositioning of

aberrant muscle and z-plasty or other local flap closure.
D7970 Excision of hyperplastic tissue - per arch E1

D7971 Excision of pericoronal gingival E1

Removal of inflammatory or hypertrophied tissues surrounding

partially erupted/impacted teeth.
Cross Reference 41821
D7972 Surgical reduction of fibrous tuberosity E1

D7979 Non surgical sialolithotomy E1

A sialolith is removed from the gland or ductal portion of the gland

without surgical incision into the gland or the duct of the gland; for
example via manual manipulation, ductal dilation, or any other non-
surgical method.
D7980 Surgical sialolithotomy E1

Procedure by which a stone within a salivary gland or its duct is

removed, either intraorally or extraorally.
Cross Reference 42330, 42335, 42340
D7981 Excision of salivary gland, by report E1

Cross Reference 42408

D7982 Sialodochoplasty E1

Procedure for the repair of a defect and/or restoration of a portion of

a salivary gland duct.
Cross Reference 42500
D7983 Closure of salivary fistula E1

Closure of an opening between a salivary duct and/or gland and the

cutaneous surface, or an opening into the oral cavity through other
than the normal anatomic pathway.
Cross Reference 42600
D7990 Emergency tracheotomy E1

Formation of a tracheal opening usually below the cricoid cartilage

to allow for respiratory exchange.
Cross Reference 21070
D7991 Coronoidectomy E1

Removal of the coronoid process of the mandible.

Cross Reference 21070
D7993 Surgical placement of craniofacial implant – extra oral
Surgical placement of a craniofacial implant to aid in retention of an
auricular, nasal, or orbital prosthesis.
D7994 Surgical placement: zygomatic implant
An implant placed in the zygomatic bone and exiting though the
maxillary mucosal tissue providing support and attachment of a
maxillary dental prosthesis.

D7995 Synthetic graft - mandible or facial bones, by report E1

Includes allogenic material.

Cross Reference 21299
D7996 Implant-mandible for augmentation purposes (excluding alveolar
ridge), by report E1

Cross Reference 21299

 D7997 Appliance removal (not by dentist who placed appliance), includes
removal of archbar E1

D7998 Intraoral placement of a fixation device not in conjunction with a

fracture E1

The placement of intermaxillary fixation appliance for documented

medically accepted treatments not in association with fractures.

None
D7999 Unspecified oral surgery procedure, by report E1

Used for procedure that is not adequately described by a code.

Describe procedure.
Cross Reference 21299

Orthodontics (D8010-D8999)
Limited Orthodontic Treatment
D8010 Limited orthodontic treatment of the primary dentition E1

D8020 Limited orthodontic treatment of the transitional dentition E1

D8030 Limited orthodontic treatment of the adolescent dentition E1

D8040 Limited orthodontic treatment of the adult dentition E1

Comprehensive Orthodontic Treatment

D8070 Comprehensive orthodontic treatment of the transitional dentition
E1
D8080 Comprehensive orthodontic treatment of the adolescent dentition
E1
D8090 Comprehensive orthodontic treatment of the adult dentition E1

Minor Treatment to Control Harmful Habits

D8210 Removable appliance therapy E1

Removable indicates patient can remove; includes appliances for

thumb sucking and tongue thrusting.
D8220 Fixed appliance therapy E1

Fixed indicates patient cannot remove appliance; includes

appliances for thumb sucking and tongue thrusting.

Other Orthodontic Services

 D8660 Pre-orthodontic treatment examination to monitor growth and
development E1

Periodic observation of patient dentition, at intervals established by

the dentist, to determine when orthodontic treatment should begin.
Diagnostic procedures are documented separately.
D8670 Periodic orthodontic treatment visit E1

D8680 Orthodontic retention (removal of appliances, construction and

placement of retainer(s)) E1

D8681 Removable orthodontic retainer adjustment E1

D8695 Removal of fixed orthodontic appliances for reasons other than

completion of treatment E1

D8696 Repair of orthodontic appliance - maxillary E1

Does not include bracket and standard fixed orthodontic appliances.

It does include functional appliances and palatal expanders.
D8697 Repair of orthodontic appliance - mandibular E1

Does not include bracket and standard fixed orthodontic appliances.

It does include functional appliances and palatal expanders.
D8698 Re-cement or re-bond fixed retainer - maxillary E1

D8699 Re-cement or re-bond fixed retainer - mandibular E1

D8701 Repair of fixed retainer, includes reattachment - maxillary E1

D8702 Repair of fixed retainer, includes reattachment - mandibular E1

D8703 Replacement of lost or broken retainer - maxillary E1

D8704 Replacement of lost or broken retainer - mandibular E1

None
D8999 Unspecified orthodontic procedure, by report E1

Used for procedure that is not adequately described by a code.

Describe procedure.

Adjunctive General Services (D9110-D9999)

Unclassified Treatment
D9110 Palliative treatment of dental pain - per visit N

Treatment that relieves pain but is not curative; services provided do

not have distinct procedure codes.
D9120 Fixed partial denture sectioning E1

Separation of one or more connections between abutments and/or

 pontics when some portion of a fixed prosthesis is to remain intact
and serviceable following sectioning and extraction or other
treatment. Includes all recontouring and polishing of retained
portions.
D9130 Temporomandibular joint dysfunction - non-invasive physical
therapies E1

Anesthesia
D9210 Local anesthesia not in conjunction with operative or surgical
procedures E1

Cross Reference 90784

D9211 Regional block anesthesia E1

Cross Reference 01995

D9212 Trigeminal division block anesthesia E1

Cross Reference 64400

D9215 Local anesthesia in conjunction with operative or surgical
procedures E1

Cross Reference 90784

D9219 Evaluation for moderate sedation or general anesthesia E1

D9222 Deep sedation/general anesthesia first 15 minutes E1

Anesthesia time begins when the doctor administering the anesthetic

agent initiates the appropriate anesthesia and non-invasive
monitoring protocol and remains in continuous attendance of the
patient. Anesthesia services are considered completed when the
patient may be safely left under the observation of trained personnel
and the doctor may safely leave the room to attend to other patients
or duties.
The level of anesthesia is determined by the anesthesia provider’s
documentation of the anesthetic effects upon the central nervous
system and not dependent upon the route of administration.
D9223 Deep sedation/general anesthesia - each subsequent 15 minute
increment E1

D9230 Inhalation of nitrous oxide/analgesia, anxiolysis N

D9239 Intravenous moderate (conscious) sedation/analgesia - first 15

minutes E1

Anesthesia time begins when the doctor administering the anesthetic

agent initiates the appropriate anesthesia and non-invasive
 monitoring protocol and remains in continuous attendance of the
patient. Anesthesia services are considered completed when the
patient may be safely left under the observation of trained personnel
and the doctor may safely leave the room to attend to other patients
or duties.
The level of anesthesia is determined by the anesthesia provider’s
documentation of the anesthetic effects upon the central nervous
system and not dependent upon the route of administration.
D9243 Intravenous moderate (conscious) sedation/analgesia - each
subsequent 15 minute increment E1

D9248 Non-intravenous conscious sedation N

This includes non-IV minimal and moderate sedation. A medically

controlled state of depressed consciousness while maintaining the
patient’s airway, protective reflexes and the ability to respond to
stimulation or verbal commands. It includes nonintravenous
administration of sedative and/or analgesic agent(s) and appropriate
monitoring.
The level of anesthesia is determined by the anesthesia provider’s
documentation of the anesthetic’s effects upon the central nervous
system and not dependent upon the route of administration.

Professional Consultation
D9310 Consultation - diagnostic service provided by dentist or physician
other than requesting dentist or physician E1

A patient encounter with a practitioner whose opinion or advice

regarding evaluation and/or management of a specific problem; may
be requested by another practitioner or appropriate source. The
consultation includes an oral evaluation. The consulted practitioner
may initiate diagnostic and/or therapeutic services.
D9311 Consultation with a medical health care professional E1

Treating dentist consults with a medical health care professional

concerning medical issues that may affect patient’s planned dental
treatment.

Professional Visits
D9410 House/extended care facility call E1

Includes visits to nursing homes, long-term care facilities, hospice

sites, institutions, etc. Report in addition to reporting appropriate
 code numbers for actual services performed.
D9420 Hospital or ambulatory surgical center call E1

Care provided outside the dentist’s office to a patient who is in a

hospital or ambulatory surgical center. Services delivered to the
patient on the date of service are documented separately using the
applicable procedure codes.
D9430 Office visit for observation (during regularly scheduled hours) - no
other services performed E1

D9440 Office visit-after regularly scheduled hours E1

Cross Reference 99050

D9450 Case presentation, subsequent to detailed and extensive treatment
planning E1

Established patient. Not performed on same day as evaluation.

Drugs
D9610 Therapeutic parenteral drug, single administration E1

Includes single administration of antibiotics, steroids, anti-

inflammatory drugs, or other therapeutic medications. This code
should not be used to report administration of sedative, anesthetic or
reversal agents.
D9612 Therapeutic parenteral drugs, two or more administrations, different
medications E1

Includes multiple administrations of antibiotics, steroids, anti-

inflammatory drugs or other therapeutic medications. This code
should not be used to report administration of sedatives, anesthetic
or reversal agents. This code should be reported when two or more
different medications are necessary and should not be reported in
addition to code D9610 on the same date.
D9613 Infiltration of sustained release therapeutic drug, per quadrant E1

Infiltration of a sustained release pharmacologic agent for long

acting surgical site pain control. Not for local anesthesia purposes.
D9630 Drugs or medicaments dispensed in the office for home use B

Includes, but is not limited to oral antibiotics, oral analgesics, and

topical fluoride; does not include writing prescriptions.

Miscellaneous Services
D9910 Application of desensitizing medicament E1
 Includes in-office treatment for root sensitivity. Typically reported
on a “per visit” basis for application of topical fluoride. This code is
not to be used for bases, liners or adhesives used under restorations.
D9911 Application of desensitizing resin for cervical and/or root surface,
per tooth E1

Typically reported on a “per tooth” basis for application of adhesive

resins. This code is not to be used for bases, liners, or adhesives
used under restorations.
D9912 Pre-visit patient screening
Capture and documentation of a patient’s health status prior to or on
the scheduled date of service to evaluate risk of infectious disease
transmission if the patient is to be treated within the dental practice.
D9920 Behavior management, by report E1

May be reported in addition to treatment provided. Should be

reported in 15-minute increments.
D9930 Treatment of complications (postsurgical) - unusual circumstances,
by report S

For example, treatment of a dry socket following extraction or

removal of bony sequestrum.
D9932 Cleaning and inspection of removable complete denture, maxillary
E1
This procedure does not include any adjustments.
D9933 Cleaning and inspection of removable complete denture, mandibular
E1
This procedure does not include any adjustments.
D9934 Cleaning and inspection of removable partial denture, maxillary
E1
This procedure does not include any adjustments.
D9935 Cleaning and inspection of removable partial denture, mandibular
E1
This procedure does not include any adjustments.
D9941 Fabrication of athletic mouthguard E1

Cross Reference 21089

D9942 Repair and/or reline of occlusal guard E1

D9943 Occlusal guard adjustment E1

D9944 Occlusal guard - hard appliance, full arch E1

D9945 Occlusal guard - soft appliance, full arch E1

 D9946 Occlusal guard - hard appliance, partial arch E1

D9947 Custom sleep apnea appliance fabrication and placement E1

D9948 Adjustment of custom sleep apnea appliance E1

D9949 Repair of custom sleep apnea appliance E1

D9950 Occlusion analysis - mounted case S

Includes, but is not limited to, facebow, interocclusal records

tracings, and diagnostic wax-up; for diagnostic casts, see D0470.
D9951 Occlusal adjustment - limited S

May also be known as equilibration; reshaping the occlusal surfaces

of teeth to create harmonious contact relationships between the
maxillary and mandibular teeth. Presently includes
discing/odontoplasty/enamoplasty. Typically reported on a “per
visit” basis. This should not be reported when the procedure only
involves bite adjustment in the routine post-delivery care for a
direct/indirect restoration or fixed/removable prosthodontics.
D9952 Occlusal adjustment - complete S

Occlusal adjustment may require several appointments of varying

length, and sedation may be necessary to attain adequate relaxation
of the musculature. Study casts mounted on an articulating
instrument may be utilized for analysis of occlusal disharmony. It is
designed to achieve functional relationships and masticatory
efficiency in conjunction with restorative treatment, orthodontics,
orthognathic surgery, or jaw trauma when indicated. Occlusal
adjustment enhances the healing potential of tissues affected by the
lesions of occlusal trauma.
▶ D9953 Reline custom sleep apnea appliance (indirect) E1

Resurface dentition side of appliance with new soft or hard base

material as required to restore original form and function.
D9961 Duplicate/copy of patient’s records E1

D9970 Enamel microabrasion E1

The removal of discolored surface enamel defects resulting from

altered mineralization or decalcification of the superficial enamel
layer. Submit per treatment visit.
D9971 Odontoplasty - per tooth E1

Removal/reshaping of enamel surfaces or projections

D9972 External bleaching - per arch - performed in office E1

D9973 External bleaching - per tooth E1

 D9974 Internal bleaching - per tooth E1

D9975 External bleaching for home application, per arch; includes

materials and fabrication of custom trays E1

Non-Clinical Procedures
D9985 Sales tax E1

D9986 Missed appointment E1

D9987 Cancelled appointment E1

D9990 Certified translation or sign-language services - per visit E1

D9991 Dental case management - addressing appointment compliance

barriers E1

Individualized efforts to assist a patient to maintain scheduled

appointments by solving transportation challenges or other barriers.
D9992 Dental case management - care coordination E1

Assisting in a patient’s decisions regarding the coordination of oral

health care services across multiple providers, provider types,
specialty areas of treatment, health care settings, health care
organizations and payment systems. This is the additional time and
resources expended to provide experience or expertise beyond that
possessed by the patient.
D9993 Dental case management - motivational interviewing E1

Patient-centered, personalized counseling using methods such as

Motivational Interviewing (MI) to identify and modify behaviors
interfering with positive oral health outcomes. This is a separate
service from traditional nutritional or tobacco counseling.
D9994 Dental case management - patient education to improve oral health
literacy E1

Individual, customized communication of information to assist the

patient in making appropriate health decisions designed to improve
oral health literacy, explained in a manner acknowledging economic
circumstances and different cultural beliefs, values, attitudes,
traditions and language preferences, and adopting information and
services to these differences, which requires the expenditure of time
and resources beyond that of an oral evaluation or case presentation.
D9995 Teledentistry synchronous; real-time encounter E1

Reported in addition to other procedures (e.g., diagnostic) delivered

to the patient on the date of service.
 D9996 Teledentistry asynchronous; information stored and forwarded to
dentist for subsequent review E1

Reported in addition to other procedures (e.g., diagnostic) delivered

to the patient on the date of service.

DURABLE MEDICAL EQUIPMENT (E0100-E8002)

Canes
❂ E0100 Cane, includes canes of all materials, adjustable or fixed, with tip
Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.1; 100-03, 4, 280.2

❂ E0105 Cane, quad or three prong, includes canes of all materials,
adjustable or fixed, with tips Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.1; 100-03, 4, 280.2

Coding Clinic: 2016, Q3, P3

Crutches
❂ E0110 Crutches, forearm, includes crutches of various materials, adjustable
or fixed, pair, complete with tips and handgrips Y

Crutches are covered when prescribed for a patient who is normally

ambulatory but suffers from a condition that impairs ambulation.
Provides minimal to moderate weight support while ambulating.
IOM: 100-02, 15, 110.1; 100-03, 4, 280.1
❂ E0111 Crutch forearm, includes crutches of various materials, adjustable or
fixed, each, with tips and handgrips Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.1

❂ E0112 Crutches, underarm, wood, adjustable or fixed, pair, with pads, tips,
and handgrips Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.1

❂ E0113 Crutch underarm, wood, adjustable or fixed, each, with pad, tip, and
handgrip Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.1

❂ E0114 Crutches, underarm, other than wood, adjustable or fixed, pair, with
pads, tips and handgrips Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.1

❂ E0116 Crutch, underarm, other than wood, adjustable or fixed, with pad,
 tip, handgrip, with or without shock absorber, each Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.1

❂ E0117 Crutch, underarm, articulating, spring assisted, each Y

IOM: 100-02, 15, 110.1

✽ E0118 Crutch substitute, lower leg platform, with or without wheels, each
E1

Walkers
❂ E0130 Walker, rigid (pickup), adjustable or fixed height Y

Standard walker criteria for payment: Individual has a mobility

limitation that significantly impairs ability to participate in mobility-
related activities of daily living that cannot be adequately or safely
addressed by a cane. The patient is able to use the walker safely; the
functional mobility deficit can be resolved with use of a standard
walker.
IOM: 100-02, 15, 110.1; 100-03, 4, 280.1
❂ E0135 Walker, folding (pickup), adjustable or fixed height Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.1

❂ E0140 Walker, with trunk support, adjustable or fixed height, any type
Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.1

❂ E0141 Walker, rigid, wheeled, adjustable or fixed height Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.1

❂ E0143 Walker, folding, wheeled, adjustable or fixed height Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.1

❂ E0144 Walker, enclosed, four sided framed, rigid or folding, wheeled, with
posterior seat Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.1

❂ E0147 Walker, heavy duty, multiple braking system, variable wheel
resistance Y

Heavy-duty walker is labeled as capable of supporting more than

300 pounds
IOM: 100-02, 15, 110.1; 100-03, 4, 280.1
Figure 11 Walkers.

✽ E0148 Walker, heavy duty, without wheels, rigid or folding, any type, each
Y

Heavy-duty walker is labeled as capable of supporting more than

300 pounds
✽ E0149 Walker, heavy duty, wheeled, rigid or folding, any type
Y
Heavy-duty walker is labeled as capable of supporting more than
300 pounds
✽ E0153 Platform attachment, forearm crutch, each Y

✽ E0154 Platform attachment, walker, each Y

✽ E0155 Wheel attachment, rigid pick-up walker, per pair Y

Attachments
✽ E0156 Seat attachment, walker Y

✽ E0157 Crutch attachment, walker, each Y

✽ E0158 Leg extensions for walker, per set of four (4) Y

Leg extensions are considered medically necessary DME for

patients 6 feet tall or more.
✽ E0159 Brake attachment for wheeled walker, replacement, each
Y

Sitz Bath/Equipment
❂ E0160 Sitz type bath or equipment, portable, used with or without
commode Y

IOM: 100-03, 4, 280.1

❂ E0161 Sitz type bath or equipment, portable, used with or without
commode, with faucet attachment/s Y

IOM: 100-03, 4, 280.1

❂ E0162 Sitz bath chair Y

IOM: 100-03, 4, 280.1

Commodes
❂ E0163 Commode chair, mobile or stationary, with fixed arms
Y
IOM: 100-02, 15, 110.1; 100-03, 4, 280.1
❂ E0165 Commode chair, mobile or stationary, with detachable arms
Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.1

❂ E0167 Pail or pan for use with commode chair, replacement only
Y
IOM: 100-03, 4, 280.1
✽ E0168 Commode chair, extra wide and/or heavy duty, stationary or mobile,
with or without arms, any type, each Y

Extra-wide or heavy duty commode chair is labeled as capable of

supporting more than 300 pounds
✽ E0170 Commode chair with integrated seat lift mechanism, electric, any
type Y

✽ E0171 Commode chair with integrated seat lift mechanism, non-electric,

any type Y

E0172 Seat lift mechanism placed over or on top of toilet, any type
E1
Medicare Statute 1861 SSA
✽ E0175 Foot rest, for use with commode chair, each Y

Decubitus Care Equipment

❂ E0181 Powered pressure reducing mattress overlay/pad, alternating, with
pump, includes heavy duty Y

Requires the provider to determine medical necessity compliance.

To demonstrate the requirements in the medical policy were met,
attach KX.
IOM: 100-03, 4, 280.1; 100-08, 5, 5.2.3
❂ E0182 Pump for alternating pressure pad, for replacement only
Y
IOM: 100-03, 4, 280.1; 100-08, 5, 5.2.3
▶ ✽ E0183 Powered pressure reducing underlay/pad, alternating, with pump,
includes heavy duty Y

❂ E0184 Dry pressure mattress Y

IOM: 100-03, 4, 280.1; 100-08, 5, 5.2.3

❂ E0185 Gel or gel-like pressure pad for mattress, standard mattress length
 and width Y

IOM: 100-03, 4, 280.1; 100-08, 5, 5.2.3

❂ E0186 Air pressure mattress Y

IOM: 100-03, 4, 280.1

❂ E0187 Water pressure mattress Y

IOM: 100-03, 4, 280.1

❂ E0188 Synthetic sheepskin pad Y

IOM: 100-03, 4, 280.1; 100-08, 5, 5.2.3

❂ E0189 Lambswool sheepskin pad, any size Y

IOM: 100-03, 4, 280.1; 100-08, 5, 5.2.3

❂ E0190 Positioning cushion/pillow/wedge, any shape or size, includes all
components and accessories E1

IOM: 100-02, 15, 110.1

✽ E0191 Heel or elbow protector, each Y

✽ E0193 Powered air flotation bed (low air loss therapy) Y

❂ E0194 Air fluidized bed Y

IOM: 100-03, 4, 280.1

❂ E0196 Gel pressure mattress Y

IOM: 100-03, 4, 280.1

❂ E0197 Air pressure pad for mattress, standard mattress length and width
Y

IOM: 100-03, 4, 280.1

❂ E0198 Water pressure pad for mattress, standard mattress length and width
Y

IOM: 100-03, 4, 280.1

❂ E0199 Dry pressure pad for mattress, standard mattress length and width
Y

IOM: 100-03, 4, 280.1

Heat/Cold Application
❂ E0200 Heat lamp, without stand (table model), includes bulb, or infrared
element Y

Covered when medical review determines patient’s medical

condition is one for which application of heat by heat lamp is
therapeutically effective
 IOM: 100-02, 15, 110.1; 100-03, 4, 280.1
✽ E0202 Phototherapy (bilirubin) light with photometer Y

E0203 Therapeutic lightbox, minimum 10,000 lux, table top model

E1
IOM: 100-03, 4, 280.1
❂ E0205 Heat lamp, with stand, includes bulb, or infrared element
IOM: 100-02, 15, 110.1; 100-03, 4, 280.1 Y
❂ E0210 Electric heat pad, standard Y

Flexible device containing electric resistive elements producing

heat; has fabric cover to prevent burns; with or without timing
devices for automatic shut-off
IOM: 100-03, 4, 280.1
❂ E0215 Electric heat pad, moist Y

Flexible device containing electric resistive elements producing

heat. Must have component that will absorb and retain liquid
(water).
IOM: 100-03, 4, 280.1
❂ E0217 Water circulating heat pad with pump Y

Consists of flexible pad containing series of channels through which

water is circulated by means of electrical pumping mechanism and
heated in external reservoir
IOM: 100-03, 4, 280.1
❂ E0218 Fluid circulating cold pad with pump, any type Y

IOM: 100-03, 4, 280.1

✽ E0221 Infrared heating pad system Y

❂ E0225 Hydrocollator unit, includes pads Y

IOM: 100-02, 15, 230; 100-03, 4, 280.1

E0231 Non-contact wound warming device (temperature control unit, AC
adapter and power cord) for use with warming card and wound
cover E1

IOM: 100-02, 16, 20

E0232 Warming card for use with the noncontact wound warming device
and non-contact wound warming wound cover E1

IOM: 100-02, 16, 20

❂ E0235 Paraffin bath unit, portable, (see medical supply code A4265 for
paraffin) Y
 Ordered by physician and patient’s condition expected to be relieved
by long-term use of modality
IOM: 100-02, 15, 230; 100-03, 4, 280.1
❂ E0236 Pump for water circulating pad Y

IOM: 100-03, 4, 280.1

❂ E0239 Hydrocollator unit, portable Y

IOM: 100-02, 15, 230; 100-03, 4, 280.1

Bath and Toilet Aids

E0240 Bath/shower chair, with or without wheels, any size E1

IOM: 100-03, 4, 280.1

E0241 Bath tub wall rail, each E1

IOM: 100-02, 15, 110.1; 100-03, 4, 280.1

E0242 Bath tub rail, floor base E1

IOM: 100-02, 15, 110.1; 100-03, 4, 280.1

E0243 Toilet rail, each E1

IOM: 100-02, 15, 110.1; 100-03, 4, 280.1

E0244 Raised toilet seat E1

IOM: 100-03, 4, 280.1

E0245 Tub stool or bench E1

IOM: 100-03, 4, 280.1

✽ E0246 Transfer tub rail attachment E1

❂ E0247 Transfer bench for tub or toilet with or without commode opening
E1

IOM: 100-03, 4, 280.1

❂ E0248 Transfer bench, heavy duty, for tub or toilet with or without
commode opening E1

Heavy duty transfer bench is labeled as capable of supporting more

than 300 pounds
IOM: 100-03, 4, 280.1

Pad for Heating Unit

❂ E0249 Pad for water circulating heat unit, for replacement only
Y
Describes durable replacement pad used with water circulating
heat pump system
 IOM: 100-03, 4, 280.1

Hospital Beds and Accessories

❂ E0250 Hospital bed, fixed height, with any type side rails, with mattress
Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.7

❂ E0251 Hospital bed, fixed height, with any type side rails, without mattress
Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.7

❂ E0255 Hospital bed, variable height, hi-lo, with any type side rails, with
mattress Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.7

❂ E0256 Hospital bed, variable height, hi-lo, with any type side rails, without
mattress Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.7

❂ E0260 Hospital bed, semi-electric (head and foot adjustment), with any
type side rails, with mattress Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.7

❂ E0261 Hospital bed, semi-electric (head and foot adjustment), with any
type side rails, without mattress Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.7

❂ E0265 Hospital bed, total electric (head, foot and height adjustments), with
any type side rails, with mattress Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.7

❂ E0266 Hospital bed, total electric (head, foot and height adjustments), with
any type side rails, without mattress Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.7

E0270 Hospital bed, institutional type includes: oscillating, circulating and
Stryker frame, with mattress E1

IOM: 100-03, 4, 280.1

❂ E0271 Mattress, innerspring Y

IOM: 100-03, 4, 280.1; 100-03, 4, 280.7

❂ E0272 Mattress, foam rubber Y

IOM: 100-03, 4, 280.1; 100-03, 4, 280.7

E0273 Bed board E1

IOM: 100-03, 4, 280.1

E0274 Over-bed table E1

IOM: 100-03, 4, 280.1

❂ E0275 Bed pan, standard, metal or plastic Y

IOM: 100-03, 4, 280.1

❂ E0276 Bed pan, fracture, metal or plastic Y

IOM: 100-03, 4, 280.1

❂ E0277 Powered pressure-reducing air mattress Y

IOM: 100-03, 4, 280.1

✽ E0280 Bed cradle, any type Y

❂ E0290 Hospital bed, fixed height, without side rails, with mattress
Y
IOM: 100-02, 15, 110.1; 100-03, 4, 280.7
❂ E0291 Hospital bed, fixed height, without side rails, without mattress
Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.7

❂ E0292 Hospital bed, variable height, hi-lo, without side rails, with mattress
Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.7

❂ E0293 Hospital bed, variable height, hi-lo, without side rails, without
mattress Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.7

❂ E0294 Hospital bed, semi-electric (head and foot adjustment), without side
rails, with mattress Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.7

❂ E0295 Hospital bed, semi-electric (head and foot adjustment), without side
rails, without mattress Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.7

❂ E0296 Hospital bed, total electric (head, foot and height adjustments),
without side rails, with mattress Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.7

❂ E0297 Hospital bed, total electric (head, foot and height adjustments),
without side rails, without mattress Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.7

✽ E0300 Pediatric crib, hospital grade, fully enclosed, with or without top
enclosure Y

❂ E0301 Hospital bed, heavy duty, extra wide, with weight capacity greater
 than 350 pounds, but less than or equal to 600 pounds, with any type
side rails, without mattress Y

IOM: 100-03, 4, 280.7

❂ E0302 Hospital bed, extra heavy duty, extra wide, with weight capacity
greater than 600 pounds, with any type side rails, without mattress
Y

IOM: 100-03, 4, 280.7

❂ E0303 Hospital bed, heavy duty, extra wide, with weight capacity greater
than 350 pounds, but less than or equal to 600 pounds, with any type
side rails, with mattress Y

IOM: 100-03, 4, 280.7

❂ E0304 Hospital bed, extra heavy duty, extra wide, with weight capacity
greater than 600 pounds, with any type side rails, with mattress
Y

IOM: 100-03, 4, 280.7

❂ E0305 Bed side rails, half length Y

IOM: 100-03, 4, 280.7

❂ E0310 Bed side rails, full length Y

IOM: 100-03, 4, 280.7

E0315 Bed accessory: board, table, or support device, any type
E1
IOM: 100-03, 4, 280.1
✽ E0316 Safety enclosure frame/canopy for use with hospital bed, any type
Y

❂ E0325 Urinal; male, jug-type, any material ♂ Y

IOM: 100-03, 4, 280.1

❂ E0326 Urinal; female, jug-type, any material ♀ Y

IOM: 100-03, 4, 280.1

✽ E0328 Hospital bed, pediatric, manual, 360 degree side enclosures, top of
headboard, footboard and side rails up to 24 inches above the
spring, includes mattress Y

✽ E0329 Hospital bed, pediatric, electric or semi-electric, 360 degree side

enclosures, top of headboard, footboard and side rails up to 24
inches above the spring, includes mattress Y

✽ E0350 Control unit for electronic bowel irrigation/evacuation system

E1
Pulsed Irrigation Enhanced Evacuation (PIEE) is pulsed irrigation of
severely impacted fecal material and may be necessary for patients
 who have not responded to traditional bowel program.
✽ E0352 Disposable pack (water reservoir bag, speculum, valving
mechanism and collection bag/box) for use with the electronic
bowel irrigation/evacuation system E1

Therapy kit includes 1 B-Valve circuit, 2 containment bags, 1

lubricating jelly, 1 bed pad, 1 tray liner-waste disposable bag, and 2
hose clamps
✽ E0370 Air pressure elevator for heel E1

✽ E0371 Non powered advanced pressure reducing overlay for mattress,

standard mattress length and width Y

Patient has at least one large Stage III or Stage IV pressure sore
(greater than 2 × 2 cm.) on trunk, with only two turning surfaces on
which to lie
✽ E0372 Powered air overlay for mattress, standard mattress length and width
Y

✽ E0373 Non powered advanced pressure reducing mattress Y

Oxygen and Related Respiratory Equipment

❂ E0424 Stationary compressed gaseous oxygen system, rental; includes
container, contents, regulator, flowmeter, humidifier, nebulizer,
cannula or mask, and tubing Y

IOM: 100-03, 4, 280.1; 100-04, 20, 30.6

❂ E0425 Stationary compressed gas system, purchase; includes regulator,
flowmeter, humidifier, nebulizer, cannula or mask, and tubing
E1
IOM: 100-03, 4, 280.1; 100-04, 20, 30.6
❂ E0430 Portable gaseous oxygen system, purchase; includes regulator,
flowmeter, humidifier, cannula or mask, and tubing E1

IOM: 100-03, 4, 280.1; 100-04, 20, 30.6

❂ E0431 Portable gaseous oxygen system, rental; includes portable container,
regulator, flowmeter, humidifier, cannula or mask, and tubing
Y

IOM: 100-03, 4, 280.1; 100-04, 20, 30.6

✽ E0433 Portable liquid oxygen system, rental; home liquefier used to fill
portable liquid oxygen containers, includes portable containers,
regulator, flowmeter, humidifier, cannula or mask and tubing, with
or without supply reservoir and contents gauge Y
❂ E0434 Portable liquid oxygen system, rental; includes portable container,
supply reservoir, humidifier, flowmeter, refill adaptor, contents
gauge, cannula or mask, and tubing Y

Fee schedule payments for stationary oxygen system rentals are all-
inclusive and represent monthly allowance for beneficiary. Non-
Medicare payers may rent device to beneficiaries, or arrange for
purchase of device.
IOM: 100-03, 4, 280.1; 100-04, 20, 30.6
❂ E0435 Portable liquid oxygen system, purchase; includes portable
container, supply reservoir, flowmeter, humidifier, contents gauge,
cannula or mask, tubing and refill adaptor E1

IOM: 100-03, 4, 280.1; 100-04, 20, 30.6

❂ E0439 Stationary liquid oxygen system, rental; includes container,
contents, regulator, flowmeter, humidifier, nebulizer, cannula or
mask, and tubing Y

This allowance includes payment for equipment, contents, and

accessories furnished during rental month
IOM: 100-03, 4, 280.1; 100-04, 20, 30.6
❂ E0440 Stationary liquid oxygen system, purchase; includes use of reservoir,
contents indicator, regulator, flowmeter, humidifier, nebulizer,
cannula or mask, and tubing E1

IOM: 100-03, 4, 280.1; 100-04, 20, 30.6

❂ E0441 Stationary oxygen contents, gaseous, 1 month’s supply = 1 unit
Y

IOM: 100-03, 4, 280.1; 100-04, 20, 30.6

❂ E0442 Stationary oxygen contents, liquid, 1 month’s supply = 1 unit
Y

IOM: 100-03, 4, 280.1; 100-04, 20, 30.6

❂ E0443 Portable oxygen contents, gaseous, 1 month’s supply = 1 unit
Y

IOM: 100-03, 4, 280.1; 100-04, 20, 30.6

❂ E0444 Portable oxygen contents, liquid, 1 month’s supply = 1 unit
Y
IOM: 100-03, 4, 280.1; 100-04, 20, 30.6
Figure 12 Oximeter device.

✽ E0445 Oximeter device for measuring blood oxygen levels noninvasively

N

✽ E0446 Topical oxygen delivery system, not otherwise specified, includes

all supplies and accessories A

❂ E0447 Portable oxygen contents, liquid, 1 month’s supply = 1 unit,

prescribed amount at rest or nighttime exceeds 4 liters per minute
(lpm) Y

❂ E0455 Oxygen tent, excluding croup or pediatric tents Y

IOM: 100-03, 4, 280.1; 100-04, 20, 30.6

E0457 Chest shell (cuirass) E1

E0459 Chest wrap E1

✽ E0462 Rocking bed with or without side rails Y

❂ E0465 Home ventilator, any type, used with invasive interface (e.g.,
tracheostomy tube) Y

IOM: 100-03, 4, 280.1

❂ E0466 Home ventilator, any type, used with non-invasive interface (e.g.,
mask, chest shell) Y

IOM: 100-03, 4, 280.1

❂ E0467 Home ventilator, multi-function respiratory device, also performs
any or all of the additional functions of oxygen concentration, drug
nebulization, aspiration, and cough stimulation, includes all
accessories, components and supplies for all functions Y

❂ E0470 Respiratory assist device, bi-level pressure capability, without

backup rate feature, used with noninvasive interface, e.g., nasal or
facial mask (intermittent assist device with continuous positive
airway pressure device) Y

IOM: 100-03, 4, 240.2

 ❂ E0471 Respiratory assist device, bi-level pressure capability, with back-up
rate feature, used with noninvasive interface, e.g., nasal or facial
mask (intermittent assist device with continuous positive airway
pressure device) Y

IOM: 100-03, 4, 240.2

❂ E0472 Respiratory assist device, bi-level pressure capability, with backup
rate feature, used with invasive interface, e.g., tracheostomy tube
(intermittent assist device with continuous positive airway pressure
device) Y

IOM: 100-03, 4, 240.2

❂ E0480 Percussor, electric or pneumatic, home model Y

IOM: 100-03, 4, 240.2

E0481 Intrapulmonary percussive ventilation system and related
accessories E1

IOM: 100-03, 4, 240.2

✽ E0482 Cough stimulating device, alternating positive and negative airway
pressure Y

✽ E0483 High frequency chest wall oscillation system, with full anterior
and/or posterior thoracic region receiving simultaneous external
oscillation, includes all accessories and supplies, each
Y
✽ E0484 Oscillatory positive expiratory pressure device, non-electric, any
type, each Y

✽ E0485 Oral device/appliance used to reduce upper airway collapsibility,

adjustable or non-adjustable, prefabricated, includes fitting and
adjustment Y

✽ E0486 Oral device/appliance used to reduce upper airway collapsibility,

adjustable or non-adjustable, custom fabricated, includes fitting and
adjustment Y

❂ E0487 Spirometer, electronic, includes all accessories N

IPPB Machines
❂ E0500 IPPB machine, all types, with built-in nebulization; manual or
automatic valves; internal or external power source Y

IOM: 100-03, 4, 240.2

Humidifiers/Nebulizers/Compressors for Use with Oxygen IPPB Equipment

 ❂ E0550 Humidifier, durable for extensive supplemental humidification
during IPPB treatments or oxygen delivery Y

IOM: 100-03, 4, 240.2

❂ E0555 Humidifier, durable, glass or autoclavable plastic bottle type, for use
with regulator or flowmeter Y

IOM: 100-03, 4, 280.1; 100-04, 20, 30.6

❂ E0560 Humidifier, durable for supplemental humidification during IPPB
treatment or oxygen delivery Y

IOM: 100-03, 4, 280.1

Figure 13 Nebulizer

✽ E0561 Humidifier, non-heated, used with positive airway pressure device

Y

✽ E0562 Humidifier, heated, used with positive airway pressure device

Y

✽ E0565 Compressor, air power source for equipment which is not self-
contained or cylinder driven Y

❂ E0570 Nebulizer, with compressor Y

IOM: 100-03, 4, 240.2; 100-03, 4, 280.1

✽ E0572 Aerosol compressor, adjustable pressure, light duty for intermittent
use Y

✽ E0574 Ultrasonic/electronic aerosol generator with small volume nebulizer

Y

❂ E0575 Nebulizer, ultrasonic, large volume Y

IOM: 100-03, 4, 240.2

 ❂ E0580 Nebulizer, durable, glass or autoclavable plastic, bottle type, for use
with regulator or flowmeter Y

IOM: 100-03, 4, 240.2; 100-03, 4, 280.1

❂ E0585 Nebulizer, with compressor and heater Y

IOM: 100-03, 4, 240.2; 100-03, 4, 280.1

Suction Pump/CPAP
❂ E0600 Respiratory suction pump, home model, portable or stationary,
electric Y

IOM: 100-03, 4, 240.2

❂ E0601 Continuous positive airway pressure (CPAP) device Y

IOM: 100-03, 4, 240.4

Breast Pump
✽ E0602 Breast pump, manual, any type ♀ Y

Bill either manual breast pump or breast pump kit

✽ E0603 Breast pump, electric (AC and/or DC), any type ♀ N

✽ E0604 Breast pump, hospital grade, electric (AC and/or DC), any type
♀ A

Other Breathing Aids

❂ E0605 Vaporizer, room type Y

IOM: 100-03, 4, 240.2

❂ E0606 Postural drainage board Y

IOM: 100-03, 4, 240.2

Monitoring Equipment
❂ E0607 Home blood glucose monitor Y

Document recipient or caregiver is competent to monitor equipment

and that device is designed for home rather than clinical use
IOM: 100-03, 4, 280.1; 100-03, 1, 40.2
❂ E0610 Pacemaker monitor, self-contained, (checks battery depletion,
includes audible and visible check systems) Y

IOM: 100-03, 1, 20.8

❂ E0615 Pacemaker monitor, self-contained, checks battery depletion and
 other pacemaker components, includes digital/visible check systems
Y

IOM: 100-03, 1, 20.8

✽ E0616 Implantable cardiac event recorder with memory, activator and
programmer N

Assign when two 30-day pre-symptom external loop recordings fail

to establish a definitive diagnosis

Figure 14 Glucose monitor.

✽ E0617 External defibrillator with integrated electrocardiogram analysis

Y

✽ E0618 Apnea monitor, without recording feature Y

✽ E0619 Apnea monitor, with recording feature Y

✽ E0620 Skin piercing device for collection of capillary blood, laser, each
Y

Patient Lifts
❂ E0621 Sling or seat, patient lift, canvas or nylon Y

IOM: 100-03, 4, 240.2, 280.4

E0625 Patient lift, bathroom or toilet, not otherwise classified E1

IOM: 100-03, 4, 240.2

❂ E0627 Seat lift mechanism, electric, any type Y

IOM: 100-03, 4, 280.4; 100-04, 4, 20

❂ E0629 Seat lift mechanism, non-electric, any type Y

IOM: 100-04, 4, 20
❂ E0630 Patient lift, hydraulic or mechanical, includes any seat, sling,
strap(s) or pad(s) Y

IOM: 100-03, 4, 240.2

❂ E0635 Patient lift, electric, with seat or sling Y

IOM: 100-03, 4, 240.2

 ✽ E0636 Multipositional patient support system, with integrated lift, patient
accessible controls Y

E0637 Combination sit to stand frame/table system, any size including

pediatric, with seat lift feature, with or without wheels E1

IOM: 100-03, 4, 240.2

E0638 Standing frame/table system, one position (e.g., upright, supine or
prone stander), any size including pediatric, with or without wheels
E1

IOM: 100-03, 4, 240.2

✽ E0639 Patient lift, moveable from room to room with disassembly and
reassembly, includes all components/accessories E1

✽ E0640 Patient lift, fixed system, includes all components/accessories

E1

E0641 Standing frame/table system, multiposition (e.g., three-way stander),

any size including pediatric, with or without wheels E1

IOM: 100-03, 4, 240.2

E0642 Standing frame/table system, mobile (dynamic stander), any size
including pediatric E1

IOM: 100-03, 4, 240.2

Pneumatic Compressor and Appliances

❂ E0650 Pneumatic compressor, non-segmental home model Y

Lymphedema pumps are classified as segmented or nonsegmented,

depending on whether distinct segments of devices can be inflated
sequentially.
IOM: 100-03, 4, 280.6
❂ E0651 Pneumatic compressor, segmental home model without calibrated
gradient pressure Y

IOM: 100-03, 4, 280.6

❂ E0652 Pneumatic compressor, segmental home model with calibrated
gradient pressure Y

IOM: 100-03, 4, 280.6

❂ E0655 Non-segmental pneumatic appliance for use with pneumatic
compressor, half arm Y

IOM: 100-03, 4, 280.6

❂ E0656 Segmental pneumatic appliance for use with pneumatic compressor,
trunk Y
❂ E0657 Segmental pneumatic appliance for use with pneumatic compressor,
chest Y

❂ E0660 Non-segmental pneumatic appliance for use with pneumatic

compressor, full leg Y

IOM: 100-03, 4, 280.6

❂ E0665 Non-segmental pneumatic appliance for use with pneumatic
compressor, full arm Y

IOM: 100-03, 4, 280.6

❂ E0666 Non-segmental pneumatic appliance for use with pneumatic
compressor, half leg Y

IOM: 100-03, 4, 280.6

❂ E0667 Segmental pneumatic appliance for use with pneumatic compressor,
full leg Y

IOM: 100-03, 4, 280.6

❂ E0668 Segmental pneumatic appliance for use with pneumatic compressor,
full arm Y

IOM: 100-03, 4, 280.6

❂ E0669 Segmental pneumatic appliance for use with pneumatic compressor,
half leg Y

IOM: 100-03, 4, 280.6

❂ E0670 Segmental pneumatic appliance for use with pneumatic compressor,
integrated, 2 full legs and trunk Y

IOM: 100-03, 4, 280.6

❂ E0671 Segmental gradient pressure pneumatic appliance, full leg
Y
IOM: 100-03, 4, 280.6
❂ E0672 Segmental gradient pressure pneumatic appliance, full arm
Y
IOM: 100-03, 4, 280.6
❂ E0673 Segmental gradient pressure pneumatic appliance, half leg
Y
IOM: 100-03, 4, 280.6
✽ E0675 Pneumatic compression device, high pressure, rapid
inflation/deflation cycle, for arterial insufficiency (unilateral or
bilateral system) Y

✽ E0676 Intermittent limb compression device (includes all accessories), not

otherwise specified Y
Ultraviolet Light Therapy Systems
✽ E0691 Ultraviolet light therapy system, includes bulbs/lamps, timer and
eye protection; treatment area 2 square feet or less Y

✽ E0692 Ultraviolet light therapy system panel, includes bulbs/lamps, timer

and eye protection, 4 foot panel Y

✽ E0693 Ultraviolet light therapy system panel, includes bulbs/lamps, timer

and eye protection, 6 foot panel Y

✽ E0694 Ultraviolet multidirectional light therapy system in 6 foot cabinet,

includes bulbs/lamps, timer and eye protection Y

Safety Equipment
✽ E0700 Safety equipment, device or accessory, any type E1

❂ E0705 Transfer device, any type, each B

Restraints
✽ E0710 Restraints, any type (body, chest, wrist or ankle) E1
Transcutaneous and/or Neuromuscular Electrical Nerve Stimulators
(TENS)
❂ E0720 Transcutaneous electrical nerve stimulation (TENS) device, two
lead, localized stimulation Y

A Certificate of Medical Necessity (CMN) is not needed for a TENS

rental, but is needed for purchase.
IOM: 100-03, 2, 160.2; 100-03, 4, 280.1
❂ E0730 Transcutaneous electrical nerve stimulation (TENS) device, four or
more leads, for multiple nerve stimulation Y

IOM: 100-03, 2, 160.2; 100-03, 4, 280.1

❂ E0731 Form-fitting conductive garment for delivery of TENS or NMES
(with conductive fibers separated from the patient’s skin by layers of
fabric) Y

IOM: 100-03, 2, 160.13

❂ E0740 Non-implanted pelvic floor electrical stimulator, complete system
Y

IOM: 100-03, 4, 230.8

✽ E0744 Neuromuscular stimulator for scoliosis Y

❂ E0745 Neuromuscular stimulator, electronic shock unit Y

IOM: 100-03, 2, 160.12

❂ E0746 Electromyography (EMG), biofeedback device N

IOM: 100-03, 1, 30.1

❂ E0747 Osteogenesis stimulator, electrical, non-invasive, other than spinal
applications Y

Devices are composed of two basic parts: Coils that wrap around
cast and pulse generator that produces electric current
❂ E0748 Osteogenesis stimulator, electrical, non-invasive, spinal applications
Y

Device should be applied within 30 days as adjunct to spinal fusion

surgery
❂ E0749 Osteogenesis stimulator, electrical, surgically implanted
N
✽ E0755 Electronic salivary reflex stimulator (intra-oral/non-invasive)
E1

✽ E0760 Osteogenesis stimulator, low intensity ultrasound, noninvasive

Y
 Ultrasonic osteogenesis stimulator may not be used concurrently
with other noninvasive stimulators
❂ E0761 Non-thermal pulsed high frequency radiowaves, high peak power
electromagnetic energy treatment device E1

✽ E0762 Transcutaneous electrical joint stimulation device system, includes

all accessories B

❂ E0764 Functional neuromuscular stimulator, transcutaneous stimulation of

sequential muscle groups of ambulation with computer control, used
for walking by spinal cord injured, entire system, after completion
of training program Y

IOM: 100-03, 2, 160.12

✽ E0765 FDA approved nerve stimulator, with replaceable batteries, for
treatment of nausea and vomiting Y

✽ E0766 Electrical stimulation device used for cancer treatment, includes all
accessories, any type Y

❂ E0769 Electrical stimulation or electromagnetic wound treatment device,

not otherwise classified B

IOM: 100-04, 32, 11.1

❂ E0770 Functional electrical stimulator, transcutaneous stimulation of nerve
and/or muscle groups, any type, complete system, not otherwise
specified Y

Infusion Supplies
✽ E0776 IV pole Y

PEN: On Fee Schedule

✽ E0779 Ambulatory infusion pump, mechanical, reusable, for infusion 8
hours or greater Y

Requires prior authorization and copy of invoice

This is a capped rental infusion pump modifier. The correct monthly
modifier (KH, KI, KJ) is used to indicate which month the rental is
for (i.e., KH, month 1; KI, months 2 and 3; KJ, months 4 through
13).
✽ E0780 Ambulatory infusion pump, mechanical, reusable, for infusion less
than 8 hours Y

Requires prior authorization and copy of invoice

❂ E0781 Ambulatory infusion pump, single or multiple channels, electric or
battery operated with administrative equipment, worn by patient
 Y

IOM: 100-03, 1, 50.3

❂ E0782 Infusion pump, implantable, non-programmable (includes all
components, e.g., pump, cathether, connectors, etc.) N

IOM: 100-03, 1, 50.3

❂ E0783 Infusion pump system, implantable, programmable (includes all
components, e.g., pump, catheter, connectors, etc.) N

IOM: 100-03, 1, 50.3

❂ E0784 External ambulatory infusion pump, insulin Y

IOM: 100-03, 4, 280.14

❂ E0785 Implantable intraspinal (epidural/intrathecal) catheter used with
implantable infusion pump, replacement N

IOM: 100-03, 1, 50.3

❂ E0786 Implantable programmable infusion pump, replacement (excludes
implantable intraspinal catheter) N

IOM: 100-03, 1, 50.3

✽ E0787 External ambulatory infusion pump, insulin, dosage rate adjustment
using therapeutic continuous glucose sensing Y

❂ E0791 Parenteral infusion pump, stationary, single or multi-channel

Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

Traction Equipment and Orthopedic Devices

❂ E0830 Ambulatory traction device, all types, each N

IOM: 100-03, 4, 280.1

❂ E0840 Traction frame, attached to headboard, cervical traction
Y
IOM: 100-03, 4, 280.1
✽ E0849 Traction equipment, cervical, free-standing stand/frame, pneumatic,
applying traction force to other than mandible Y

❂ E0850 Traction stand, free standing, cervical traction Y

IOM: 100-03, 4, 280.1

✽ E0855 Cervical traction equipment not requiring additional stand or frame
Y

✽ E0856 Cervical traction device, with inflatable air bladder(s) Y

❂ E0860 Traction equipment, overdoor, cervical Y

 IOM: 100-03, 4, 280.1
❂ E0870 Traction frame, attached to footboard, extremity traction, (e.g.,
Buck’s) Y

IOM: 100-03, 4, 280.1

❂ E0880 Traction stand, free standing, extremity traction Y

IOM: 100-03, 4, 280.1

❂ E0890 Traction frame, attached to footboard, pelvic traction Y

IOM: 100-03, 4, 280.1

❂ E0900 Traction stand, free standing, pelvic traction (e.g., Buck’s)
Y
IOM: 100-03, 4, 280.1
❂ E0910 Trapeze bars, A/K/A patient helper, attached to bed, with grab bar
Y

IOM: 100-03, 4, 280.1

❂ E0911 Trapeze bar, heavy duty, for patient weight capacity greater than 250
pounds, attached to bed, with grab bar Y

IOM: 100-03, 4, 280.1

❂ E0912 Trapeze bar, heavy duty, for patient weight capacity greater than 250
pounds, free standing, complete with grab bar Y

IOM: 100-03, 4, 280.1

❂ E0920 Fracture frame, attached to bed, includes weights Y

IOM: 100-03, 4, 280.1

❂ E0930 Fracture frame, free standing, includes weights Y

IOM: 100-03, 4, 280.1

❂ E0935 Continuous passive motion exercise device for use on knee only
Y

To qualify for coverage, use of device must commence within two

days following surgery
IOM: 100-03, 4, 280.1
E0936 Continuous passive motion exercise device for use other than knee
E1

❂ E0940 Trapeze bar, free standing, complete with grab bar Y

IOM: 100-03, 4, 280.1

❂ E0941 Gravity assisted traction device, any type Y

IOM: 100-03, 4, 280.1

✽ E0942 Cervical head harness/halter Y
 ✽ E0944 Pelvic belt/harness/boot Y

✽ E0945 Extremity belt/harness Y

❂ E0946 Fracture, frame, dual with cross bars, attached to bed (e.g., Balken,
4 poster) Y

IOM: 100-03, 4, 280.1

❂ E0947 Fracture frame, attachments for complex pelvic traction
Y
IOM: 100-03, 4, 280.1
❂ E0948 Fracture frame, attachments for complex cervical traction
Y
IOM: 100-03, 4, 280.1

Wheelchair Accessories
❂ E0950 Wheelchair accessory, tray, each Y

IOM: 100-03, 4, 280.1

✽ E0951 Heel loop/holder, any type, with or without ankle strap, each
Y

❂ E0952 Toe loop/holder, any type, each Y

IOM: 100-03, 4, 280.1

✽ E0953 Wheelchair accessory, lateral thigh or knee support, any type,
including fixed mounting hardware, each Y

✽ E0954 Wheelchair accessory, foot box, any type, includes attachment and
mounting hardware, each foot Y

✽ E0955 Wheelchair accessory, headrest, cushioned, any type, including

fixed mounting hardware, each Y

✽ E0956 Wheelchair accessory, lateral trunk or hip support, any type,

including fixed mounting hardware, each Y

✽ E0957 Wheelchair accessory, medial thigh support, any type, including

fixed mounting hardware, each Y

❂ E0958 Manual wheelchair accessory, one-arm drive attachment, each

Y

IOM: 100-03, 4, 280.1

✽ E0959 Manual wheelchair accessory, adapter for amputee, each
B
IOM: 100-03, 4, 280.1
✽ E0960 Wheelchair accessory, shoulder harness/straps or chest strap,
including any type mounting hardware Y

✽ E0961 Manual wheelchair accessory, wheel lock brake extension (handle),

 each B

IOM: 100-03, 4, 280.1

✽ E0966 Manual wheelchair accessory, headrest extension, each
B
IOM: 100-03, 4, 280.1
❂ E0967 Manual wheelchair accessory, hand rim with projections, any type,
replacement only, each Y

IOM: 100-03, 4, 280.1

❂ E0968 Commode seat, wheelchair Y

IOM: 100-03, 4, 280.1

❂ E0969 Narrowing device, wheelchair Y

IOM: 100-03, 4, 280.1

E0970 No. 2 footplates, except for elevating leg rest E1

IOM: 100-03, 4, 280.1

Cross Reference K0037, K0042
✽ E0971 Manual wheelchair accessory, anti-tipping device, each
B
IOM: 100-03, 4, 280.1
Cross Reference K0021
❂ E0973 Wheelchair accessory, adjustable height, detachable armrest,
complete assembly, each B

IOM: 100-03, 4, 280.1

❂ E0974 Manual wheelchair accessory, anti-rollback device, each
B
IOM: 100-03, 4, 280.1
✽ E0978 Wheelchair accessory, positioning belt/safety belt/pelvic strap, each
B

✽ E0980 Safety vest, wheelchair Y

✽ E0981 Wheelchair accessory, seat upholstery, replacement only, each

Y

✽ E0982 Wheelchair accessory, back upholstery, replacement only, each

Y

✽ E0983 Manual wheelchair accessory, power add-on to convert manual

wheelchair to motorized wheelchair, joystick control Y

✽ E0984 Manual wheelchair accessory, power add-on to convert manual

wheelchair to motorized wheelchair, tiller control Y

✽ E0985 Wheelchair accessory, seat lift mechanism Y

✽ E0986 Manual wheelchair accessory, push-rim activated power assist

 system Y

✽ E0988 Manual wheelchair accessory, lever-activated, wheel drive, pair

Y

✽ E0990 Wheelchair accessory, elevating leg rest, complete assembly, each

B

IOM: 100-03, 4, 280.1

✽ E0992 Manual wheelchair accessory, solid seat insert B

❂ E0994 Arm rest, each Y

IOM: 100-03, 4, 280.1

✽ E0995 Wheelchair accessory, calf rest/pad, replacement only, each
B
IOM: 100-03, 4, 280.1
✽ E1002 Wheelchair accessory, power seating system, tilt only Y

✽ E1003 Wheelchair accessory, power seating system, recline only, without

shear reduction Y

✽ E1004 Wheelchair accessory, power seating system, recline only, with

mechanical shear reduction Y

✽ E1005 Wheelchair accessory, power seating system, recline only, with

power shear reduction Y

✽ E1006 Wheelchair accessory, power seating system, combination tilt and

recline, without shear reduction Y

✽ E1007 Wheelchair accessory, power seating system, combination tilt and

recline, with mechanical shear reduction Y

✽ E1008 Wheelchair accessory, power seating system, combination tilt and

recline, with power shear reduction Y

✽ E1009 Wheelchair accessory, addition to power seating system,

mechanically linked leg elevation system, including pushrod and leg
rest, each Y

✽ E1010 Wheelchair accessory, addition to power seating system, power leg

elevation system, including leg rest, pair Y

❂ E1011 Modification to pediatric size wheelchair, width adjustment package

(not to be dispensed with initial chair) Y

IOM: 100-03, 4, 280.1

✽ E1012 Wheelchair accessory, addition to power seating system, center
mount power elevating leg rest/platform, complete system, any type,
each Y

❂ E1014 Reclining back, addition to pediatric size wheelchair

 IOM: 100-03, 4, 280.1 Y

❂ E1015 Shock absorber for manual wheelchair, each Y

IOM: 100-03, 4, 280.1

❂ E1016 Shock absorber for power wheelchair, each Y

IOM: 100-03, 4, 280.1

❂ E1017 Heavy duty shock absorber for heavy duty or extra heavy duty
manual wheelchair, each Y

IOM: 100-03, 4, 280.1

❂ E1018 Heavy duty shock absorber for heavy duty or extra heavy duty
power wheelchair, each Y

IOM: 100-03, 4, 280.1

❂ E1020 Residual limb support system for wheelchair, any type
Y
IOM: 100-03, 3, 280.3
✽ E1028 Wheelchair accessory, manual swingaway, retractable or removable
mounting hardware for joystick, other control interface or
positioning accessory Y

✽ E1029 Wheelchair accessory, ventilator tray, fixed Y

✽ E1030 Wheelchair accessory, ventilator tray, gimbaled Y

Rollabout Chair, Transfer System, Transport Chair

❂ E1031 Rollabout chair, any and all types with casters 5” or greater
Y
IOM: 100-03, 4, 280.1
❂ E1035 Multi-positional patient transfer system, with integrated seat,
operated by care giver, patient weight capacity up to and including
300 lbs Y

IOM: 100-02, 15, 110

✽ E1036 Multi-positional patient transfer system, extra-wide, with integrated
seat, operated by caregiver, patient weight capacity greater than 300
lbs Y

❂ E1037 Transport chair, pediatric size Y

IOM: 100-03, 4, 280.1

❂ E1038 Transport chair, adult size, patient weight capacity up to and
including 300 pounds Y

IOM: 100-03, 4, 280.1

✽ E1039 Transport chair, adult size, heavy duty, patient weight capacity
 greater than 300 pounds Y

Wheelchair: Fully Reclining

❂ E1050 Fully-reclining wheelchair, fixed full length arms, swing away
detachable elevating leg rests Y

IOM: 100-03, 4, 280.1

❂ E1060 Fully-reclining wheelchair, detachable arms, desk or full length,
swing away detachable elevating legrests Y

IOM: 100-03, 4, 280.1

❂ E1070 Fully-reclining wheelchair, detachable arms (desk or full length),
swing away detachable footrests Y

IOM: 100-03, 4, 280.1

Wheelchair: Hemi
❂ E1083 Hemi-wheelchair, fixed full length arms, swing away detachable
elevating leg rest Y

IOM: 100-03, 4, 280.1

❂ E1084 Hemi-wheelchair, detachable arms desk or full length arms, swing
away detachable elevating leg rests Y

IOM: 100-03, 4, 280.1

E1085 Hemi-wheelchair, fixed full length arms, swing away detachable
foot rests E1

IOM: 100-03, 4, 280.1

Cross Reference K0002
E1086 Hemi-wheelchair, detachable arms desk or full length, swing away
detachable footrests E1

IOM: 100-03, 4, 280.1

Cross Reference K0002

Wheelchair: High-strength Lightweight

❂ E1087 High strength lightweight wheelchair, fixed full length arms, swing
away detachable elevating leg rests Y

IOM: 100-03, 4, 280.1

❂ E1088 High strength lightweight wheelchair, detachable arms desk or full
length, swing away detachable elevating leg rests Y

IOM: 100-03, 4, 280.1

 E1089 High strength lightweight wheelchair, fixed length arms, swing
away detachable footrest E1

IOM: 100-03, 4, 280.1

Cross Reference K0004
E1090 High strength lightweight wheelchair, detachable arms desk or full
length, swing away detachable foot rests E1

IOM: 100-03, 4, 280.1

Cross Reference K0004

Wheelchair: Wide Heavy Duty

❂ E1092 Wide heavy duty wheelchair, detachable arms (desk or full length),
swing away detachable elevating leg rests Y

IOM: 100-03, 4, 280.1

❂ E1093 Wide heavy duty wheelchair, detachable arms (desk or full length
arms), swing away detachable foot rests Y

IOM: 100-03, 4, 280.1

Wheelchair: Semi-reclining
❂ E1100 Semi-reclining wheelchair, fixed full length arms, swing away
detachable elevating leg rests Y

IOM: 100-03, 4, 280.1

❂ E1110 Semi-reclining wheelchair, detachable arms (desk or full length),
elevating leg rest Y

IOM: 100-03, 4, 280.1

Wheelchair: Standard
E1130 Standard wheelchair, fixed full length arms, fixed or swing away
detachable footrests E1

IOM: 100-03, 4, 280.1

Cross Reference K0001
E1140 Wheelchair, detachable arms, desk or full length, swing away
detachable footrests E1

IOM: 100-03, 4, 280.1

Cross Reference K0001
❂ E1150 Wheelchair, detachable arms, desk or full length, swing away
detachable elevating legrests Y
 IOM: 100-03, 4, 280.1
❂ E1160 Wheelchair, fixed full length arms, swing away detachable elevating
legrests Y

IOM: 100-03, 4, 280.1

✽ E1161 Manual adult size wheelchair, includes tilt in space Y

Wheelchair: Amputee
❂ E1170 Amputee wheelchair, fixed full length arms, swing away detachable
elevating legrests Y

IOM: 100-03, 4, 280.1

❂ E1171 Amputee wheelchair, fixed full length arms, without footrests or
legrest Y

IOM: 100-03, 4, 280.1

❂ E1172 Amputee wheelchair, detachable arms (desk or full length) without
footrests or legrest Y

IOM: 100-03, 4, 280.1

❂ E1180 Amputee wheelchair, detachable arms (desk or full length) swing
away detachable footrests Y

IOM: 100-03, 4, 280.1

❂ E1190 Amputee wheelchair, detachable arms (desk or full length), swing
away detachable elevating legrests Y

IOM: 100-03, 4, 280.1

❂ E1195 Heavy duty wheelchair, fixed full length arms, swing away
detachable elevating legrests Y

IOM: 100-03, 4, 280.1

❂ E1200 Amputee wheelchair, fixed full length arms, swing away detachable
footrest Y

IOM: 100-03, 4, 280.1

Wheelchair: Other and Accessories

❂ E1220 Wheelchair; specially sized or constructed (indicate brand name,
model number, if any) and justification Y

IOM: 100-03, 4, 280.3

❂ E1221 Wheelchair with fixed arm, footrests Y

IOM: 100-03, 4, 280.3

❂ E1222 Wheelchair with fixed arm, elevating legrests Y
 IOM: 100-03, 4, 280.3
❂ E1223 Wheelchair with detachable arms, footrests Y

IOM: 100-03, 4, 280.3

❂ E1224 Wheelchair with detachable arms, elevating legrests Y

IOM: 100-03, 4, 280.3

❂ E1225 Wheelchair accessory, manual semireclining back, (recline greater
than 15 degrees, but less than 80 degrees), each Y

IOM: 100-03, 4, 280.3

❂ E1226 Wheelchair accessory, manual fully reclining back, (recline greater
than 80 degrees), each B

IOM: 100-03, 4, 280.1

❂ E1227 Special height arms for wheelchair Y

IOM: 100-03, 4, 280.3

❂ E1228 Special back height for wheelchair Y

IOM: 100-03, 4, 280.3

Wheelchair: Pediatric
✽ E1229 Wheelchair, pediatric size, not otherwise specified Y

❂ E1230 Power operated vehicle (three or four wheel non-highway), specify

brand name and model number Y

Patient is unable to operate manual wheelchair; patient capable of

safely operating controls for scooter; patient can transfer safely in
and out of scooter
IOM: 100-08, 5, 5.2.3
❂ E1231 Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, with
seating system Y

IOM: 100-03, 4, 280.1

❂ E1232 Wheelchair, pediatric size, tilt-in-space, folding, adjustable, with
seating system Y

IOM: 100-03, 4, 280.1

❂ E1233 Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, without
seating system Y

IOM: 100-03, 4, 280.1

❂ E1234 Wheelchair, pediatric size, tilt-in-space, folding, adjustable, without
seating system Y

IOM: 100-03, 4, 280.1

 ❂ E1235 Wheelchair, pediatric size, rigid, adjustable, with seating system
Y

IOM: 100-03, 4, 280.1

❂ E1236 Wheelchair, pediatric size, folding, adjustable, with seating system
Y

IOM: 100-03, 4, 280.1

❂ E1237 Wheelchair, pediatric size, rigid, adjustable, without seating system
Y

IOM: 100-03, 4, 280.1

❂ E1238 Wheelchair, pediatric size, folding, adjustable, without seating
system Y

IOM: 100-03, 4, 280.1

✽ E1239 Power wheelchair, pediatric size, not otherwise specified Y

Wheelchair: Lightweight
❂ E1240 Lightweight wheelchair, detachable arms (desk or full length),
swing-away detachable elevating leg rests Y

IOM: 100-03, 4, 280.1

E1250 Lightweight wheelchair, fixed full length arms, swing away
detachable footrest E1

IOM: 100-03, 4, 280.1

Cross Reference K0003
E1260 Lightweight wheelchair, detachable arms (desk or full length),
swing-away detachable footrest E1

IOM: 100-03, 4, 280.1

Cross Reference K0003
❂ E1270 Lightweight wheelchair, fixed full length arms, swing away
detachable elevating legrests Y

IOM: 100-03, 4, 280.1

Wheelchair: Heavy Duty

❂ E1280 Heavy duty wheelchair, detachable arms (desk or full length),
elevating legrests Y

IOM: 100-03, 4, 280.1

E1285 Heavy duty wheelchair, fixed full length arms, swing away
detachable footrest E1
 IOM: 100-03, 4, 280.1
Cross Reference K0006
E1290 Heavy duty wheelchair, detachable arms (desk or full length),
swing-away detachable footrest E1

IOM: 100-03, 4, 280.1

Cross Reference K0006
❂ E1295 Heavy duty wheelchair, fixed full length arms, elevating legrest
Y

IOM: 100-03, 4, 280.1

❂ E1296 Special wheelchair seat height from floor Y

IOM: 100-03, 4, 280.3

❂ E1297 Special wheelchair seat depth, by upholstery Y

IOM: 100-03, 4, 280.3

❂ E1298 Special wheelchair seat depth and/or width, by construction Y

IOM: 100-03, 4, 280.3

Whirlpool Equipment
E1300 Whirlpool, portable (overtub type) E1

IOM: 100-03, 4, 280.1

❂ E1310 Whirlpool, non-portable (built-in type) Y

IOM: 100-03, 4, 280.1

Additional Oxygen Related Equipment

✽ E1352 Oxygen accessory, flow regulator capable of positive inspiratory
pressure Y

❂ E1353 Regulator Y

IOM: 100-03, 4, 240.2

✽ E1354 Oxygen accessory, wheeled cart for portable cylinder or portable
concentrator, any type, replacement only, each Y

❂ E1355 Stand/rack Y

IOM: 100-03, 4, 240.2

✽ E1356 Oxygen accessory, battery pack/cartridge for portable concentrator,
any type, replacement only, each Y

✽ E1357 Oxygen accessory, battery charger for portable concentrator, any

type, replacement only, each Y
 ❂ E1358 Oxygen accessory, DC power adapter for portable concentrator, any
type, replacement only, each Y

❂ E1372 Immersion external heater for nebulizer Y

IOM: 100-03, 4, 240.2

❂ E1390 Oxygen concentrator, single delivery port, capable of delivering 85
percent or greater oxygen concentration at the prescribed flow rate
Y

IOM: 100-03, 4, 240.2

❂ E1391 Oxygen concentrator, dual delivery port, capable of delivering 85
percent or greater oxygen concentration at the prescribed flow rate,
each Y

IOM: 100-03, 4, 240.2

❂ E1392 Portable oxygen concentrator, rental Y

IOM: 100-03, 4, 240.2

✽ E1399 Durable medical equipment, miscellaneous Y

Example: Therapeutic exercise putty; rubber exercise tubing; anti-

vibration gloves
On DMEPOS fee schedule as a payable replacement for
miscellaneous implanted or non-implanted items
❂ E1405 Oxygen and water vapor enriching system with heated delivery
Y

IOM: 100-03, 4, 240.2

❂ E1406 Oxygen and water vapor enriching system without heated delivery
Y

IOM: 100-03, 4, 240.2

Artificial Kidney Machines and Accessories

❂ E1500 Centrifuge, for dialysis A

❂ E1510 Kidney, dialysate delivery system, kidney machine, pump

recirculating, air removal system, flowrate meter, power off, heater
and temperature control with alarm, I.V. poles, pressure gauge,
concentrate container A

❂ E1520 Heparin infusion pump for hemodialysis A

❂ E1530 Air bubble detector for hemodialysis, each, replacement A

❂ E1540 Pressure alarm for hemodialysis, each, replacement A

❂ E1550 Bath conductivity meter for hemodialysis, each A

 ❂ E1560 Blood leak detector for hemodialysis, each, replacement A

❂ E1570 Adjustable chair, for ESRD patients A

❂ E1575 Transducer protectors/fluid barriers for hemodialysis, any size, per

10 A

❂ E1580 Unipuncture control system for hemodialysis A

❂ E1590 Hemodialysis machine A

❂ E1592 Automatic intermittent peritoneal dialysis system A

❂ E1594 Cycler dialysis machine for peritoneal dialysis A

❂ E1600 Delivery and/or installation charges for hemodialysis equipment

A

❂ E1610 Reverse osmosis water purification system, for hemodialysis

A
IOM: 100-03, 4, 230.7
❂ E1615 Deionizer water purification system, for hemodialysis A

IOM: 100-03, 4, 230.7

❂ E1620 Blood pump for hemodialysis replacement A

❂ E1625 Water softening system, for hemodialysis A

IOM: 100-03, 4, 230.7

❂ E1629 Tablo hemodialysis system for the billable dialysis service A

✽ E1630 Reciprocating peritoneal dialysis system A

❂ E1632 Wearable artificial kidney, each A

❂ E1634 Peritoneal dialysis clamps, each B

IOM: 100-04, 8, 60.4.2; 100-04, 8, 90.1; 100-04, 18, 80; 100-04,

18, 90
❂ E1635 Compact (portable) travel hemodialyzer system A

❂ E1636 Sorbent cartridges, for hemodialysis, per 10 A

❂ E1637 Hemostats, each A

❂ E1639 Scale, each A

❂ E1699 Dialysis equipment, not otherwise specified A

Jaw Motion Rehabilitation System

✽ E1700 Jaw motion rehabilitation system Y

Must be prescribed by physician

✽ E1701 Replacement cushions for jaw motion rehabilitation system, pkg. of
 6 Y

✽ E1702 Replacement measuring scales for jaw motion rehabilitation system,

pkg. of 200 Y

Other Orthopedic Devices

✽ E1800 Dynamic adjustable elbow extension/flexion device, includes soft
interface material Y

✽ E1801 Static progressive stretch elbow device, extension and/or flexion,

with or without range of motion adjustment, includes all
components and accessories Y

✽ E1802 Dynamic adjustable forearm pronation/supination device, includes

soft interface material Y

✽ E1805 Dynamic adjustable wrist extension/flexion device, includes soft

interface material Y

✽ E1806 Static progressive stretch wrist device, flexion and/or extension,

with or without range of motion adjustment, includes all
components and accessories Y

✽ E1810 Dynamic adjustable knee extension/flexion device, includes soft

interface material Y

✽ E1811 Static progressive stretch knee device, extension and/or flexion,

with or without range of motion adjustment, includes all
components and accessories Y

✽ E1812 Dynamic knee, extension/flexion device with active resistance

control Y

✽ E1815 Dynamic adjustable ankle extension/flexion device, includes soft

interface material Y

✽ E1816 Static progressive stretch ankle device, flexion and/or extension,

with or without range of motion adjustment, includes all
components and accessories Y

✽ E1818 Static progressive stretch forearm pronation/supination device with

or without range of motion adjustment, includes all components and
accessories Y

✽ E1820 Replacement soft interface material, dynamic adjustable

extension/flexion device Y

✽ E1821 Replacement soft interface material/cuffs for bi-directional static

progressive stretch device Y

✽ E1825 Dynamic adjustable finger extension/flexion device, includes soft

interface material Y
 ✽ E1830 Dynamic adjustable toe extension/flexion device, includes soft
interface material Y

✽ E1831 Static progressive stretch toe device, extension and/or flexion, with
or without range of motion adjustment, includes all components and
accessories Y

✽ E1840 Dynamic adjustable shoulder flexion/abduction/rotation device,

includes soft interface material Y

✽ E1841 Static progressive stretch shoulder device, with or without range of

motion adjustment, includes all components and accessories
Y

Miscellaneous
✽ E1902 Communication board, non-electronic augmentative or alternative
communication device Y

✽ E2000 Gastric suction pump, home model, portable or stationary, electric

Y

❂ E2100 Blood glucose monitor with integrated voice synthesizer

Y
IOM: 100-03, 4, 230.16
❂ E2101 Blood glucose monitor with integrated lancing/blood sample
Y

IOM: 100-03, 4, 230.16

▶ E2102 Adjunctive, non-implanted continuous glucose monitor or receiver
Y
▶ E2103 Non-adjunctive, non-implanted continuous glucose monitor or
receiver Y

✽ E2120 Pulse generator system for tympanic treatment of inner ear

endolymphatic fluid Y

Wheelchair Assessories: Manual and Power

✽ E2201 Manual wheelchair accessory, nonstandard seat frame, width greater
than or equal to 20 inches and less than 24 inches Y

✽ E2202 Manual wheelchair accessory, nonstandard seat frame width, 24-27

inches Y

✽ E2203 Manual wheelchair accessory, nonstandard seat frame depth, 20 to

less than 22 inches Y

✽ E2204 Manual wheelchair accessory, nonstandard seat frame depth, 22 to

25 inches Y
✽ E2205 Manual wheelchair accessory, handrim without projections (includes
ergonomic or contoured), any type, replacement only, each
Y
✽ E2206 Manual wheelchair accessory, wheel lock assembly, complete,
replacement only, each Y

✽ E2207 Wheelchair accessory, crutch and cane holder, each Y

✽ E2208 Wheelchair accessory, cylinder tank carrier, each Y

✽ E2209 Accessory arm trough, with or without hand support, each

Y
✽ E2210 Wheelchair accessory, bearings, any type, replacement only, each
Y

✽ E2211 Manual wheelchair accessory, pneumatic propulsion tire, any size,

each Y

✽ E2212 Manual wheelchair accessory, tube for pneumatic propulsion tire,

any size, each Y

✽ E2213 Manual wheelchair accessory, insert for pneumatic propulsion tire

(removable), any type, any size, each Y

✽ E2214 Manual wheelchair accessory, pneumatic caster tire, any size, each
Y

✽ E2215 Manual wheelchair accessory, tube for pneumatic caster tire, any
size, each Y

✽ E2216 Manual wheelchair accessory, foam filled propulsion tire, any size,
each Y

✽ E2217 Manual wheelchair accessory, foam filled caster tire, any size, each
Y

✽ E2218 Manual wheelchair accessory, foam propulsion tire, any size, each
Y

✽ E2219 Manual wheelchair accessory, foam caster tire, any size, each
Y

✽ E2220 Manual wheelchair accessory, solid (rubber/plastic) propulsion tire,

any size, replacement only, each Y

✽ E2221 Manual wheelchair accessory, solid (rubber/plastic) caster tire

(removable), any size, replacement only, each Y

✽ E2222 Manual wheelchair accessory, solid (rubber/plastic) caster tire with

integrated wheel, any size, replacement only, each Y

✽ E2224 Manual wheelchair accessory, propulsion wheel excludes tire, any

size, replacement only, each Y

✽ E2225 Manual wheelchair accessory, caster wheel excludes tire, any size,
 replacement only, each Y

✽ E2226 Manual wheelchair accessory, caster fork, any size, replacement

only, each Y

✽ E2227 Manual wheelchair accessory, gear reduction drive wheel, each

Y

✽ E2228 Manual wheelchair accessory, wheel braking system and lock,

complete, each Y

✽ E2230 Manual wheelchair accessory, manual standing system Y

✽ E2231 Manual wheelchair accessory, solid seat support base (replaces sling
seat), includes any type mounting hardware Y

✽ E2291 Back, planar, for pediatric size wheelchair including fixed attaching
hardware Y

✽ E2292 Seat, planar, for pediatric size wheelchair including fixed attaching
hardware Y

✽ E2293 Back, contoured, for pediatric size wheelchair including fixed

attaching hardware Y

✽ E2294 Seat, contoured, for pediatric size wheelchair including fixed

attaching hardware Y

✽ E2295 Manual wheelchair accessory, for pediatric size wheelchair,

dynamic seating frame, allows coordinated movement of multiple
positioning features Y

✽ E2300 Wheelchair accessory, power seat elevation system, any type

Y
✽ E2301 Wheelchair accessory, power standing system, any type Y

✽ E2310 Power wheelchair accessory, electronic connection between

wheelchair controller and one power seating system motor,
including all related electronics, indicator feature, mechanical
function selection switch, and fixed mounting hardware
Y
✽ E2311 Power wheelchair accessory, electronic connection between
wheelchair controller and two or more power seating system motors,
including all related electronics, indicator feature, mechanical
function selection switch, and fixed mounting hardware
Y
✽ E2312 Power wheelchair accessory, hand or chin control interface,
miniproportional remote joystick, proportional, including fixed
mounting hardware Y

✽ E2313 Power wheelchair accessory, harness for upgrade to expandable

controller, including all fasteners, connectors and mounting
 hardware, each Y

✽ E2321 Power wheelchair accessory, hand control interface, remote joystick,

nonproportional, including all related electronics, mechanical stop
switch, and fixed mounting hardware Y

✽ E2322 Power wheelchair accessory, hand control interface, multiple

mechanical switches, nonproportional, including all related
electronics, mechanical stop switch, and fixed mounting hardware
Y

✽ E2323 Power wheelchair accessory, specialty joystick handle for hand

control interface, prefabricated Y

✽ E2324 Power wheelchair accessory, chin cup for chin control interface
Y

✽ E2325 Power wheelchair accessory, sip and puff interface, nonproportional,

including all related electronics, mechanical stop switch, and
manual swingaway mounting hardware Y

✽ E2326 Power wheelchair accessory, breath tube kit for sip and puff
interface Y

✽ E2327 Power wheelchair accessory, head control interface, mechanical,

proportional, including all related electronics, mechanical direction
change switch, and fixed mounting hardware Y

✽ E2328 Power wheelchair accessory, head control or extremity control

interface, electronic, proportional, including all related electronics
and fixed mounting hardware Y

✽ E2329 Power wheelchair accessory, head control interface, contact switch

mechanism, nonproportional, including all related electronics,
mechanical stop switch, mechanical direction change switch, head
array, and fixed mounting hardware Y

✽ E2330 Power wheelchair accessory, head control interface, proximity

switch mechanism, nonproportional, including all related
electronics, mechanical stop switch, mechanical direction change
switch, head array, and fixed mounting hardware Y

✽ E2331 Power wheelchair accessory, attendant control, proportional,

including all related electronics and fixed mounting hardware
Y
✽ E2340 Power wheelchair accessory, nonstandard seat frame width, 20-23
inches Y

✽ E2341 Power wheelchair accessory, nonstandard seat frame width, 24-27

inches Y
✽ E2342 Power wheelchair accessory, nonstandard seat frame depth, 20 or 21
inches Y

✽ E2343 Power wheelchair accessory, nonstandard seat frame depth, 22-25

inches Y

✽ E2351 Power wheelchair accessory, electronic interface to operate speech

generating device using power wheelchair control interface
Y
✽ E2358 Power wheelchair accessory, Group 34 non-sealed lead acid battery,
each Y

✽ E2359 Power wheelchair accessory, Group 34 sealed lead acid battery, each
(e.g., gel cell, absorbed glassmat) Y

✽ E2360 Power wheelchair accessory, 22 NF non-sealed lead acid battery,

each Y

✽ E2361 Power wheelchair accessory, 22NF sealed lead acid battery, each
(e.g., gel cell, absorbed glassmat) Y

✽ E2362 Power wheelchair accessory, group 24 non-sealed lead acid battery,

each Y

✽ E2363 Power wheelchair accessory, group 24 sealed lead acid battery, each
(e.g., gel cell, absorbed glassmat) Y

✽ E2364 Power wheelchair accessory, U-1 non-sealed lead acid battery, each
Y

✽ E2365 Power wheelchair accessory, U-1 sealed lead acid battery, each (e.g.,
gel cell, absorbed glassmat) Y

✽ E2366 Power wheelchair accessory, battery charger, single mode, for use
with only one battery type, sealed or non-sealed, each Y

✽ E2367 Power wheelchair accessory, battery charger, dual mode, for use
with either battery type, sealed or non-sealed, each Y

✽ E2368 Power wheelchair component, drive wheel motor, replacement only

Y

✽ E2369 Power wheelchair component, drive wheel gear box, replacement

only Y

✽ E2370 Power wheelchair component, integrated drive wheel motor and

gear box combination, replacement only Y

✽ E2371 Power wheelchair accessory, group 27 sealed lead acid battery, (e.g.,
gel cell, absorbed glass mat), each Y

✽ E2372 Power wheelchair accessory, group 27 non-sealed lead acid battery,

each Y

✽ E2373 Power wheelchair accessory, hand or chin control interface, compact

 remote joystick, proportional, including fixed mounting hardware
Y

❂ E2374 Power wheelchair accessory, hand or chin control interface, standard

remote joystick (not including controller), proportional, including
all related electronics and fixed mounting hardware, replacement
only Y

❂ E2375 Power wheelchair accessory, nonexpandable controller, including all

related electronics and mounting hardware, replacement only
Y

❂ E2376 Power wheelchair accessory, expandable controller, including all

related electronics and mounting hardware, replacement only
Y

❂ E2377 Power wheelchair accessory, expandable controller, including all

related electronics and mounting hardware, upgrade provided at
initial issue Y

✽ E2378 Power wheelchair component, actuator, replacement only

Y
❂ E2381 Power wheelchair accessory, pneumatic drive wheel tire, any size,
replacement only, each Y

❂ E2382 Power wheelchair accessory, tube for pneumatic drive wheel tire,
any size, replacement only, each Y

❂ E2383 Power wheelchair accessory, insert for pneumatic drive wheel tire
(removable), any type, any size, replacement only, each
Y
❂ E2384 Power wheelchair accessory, pneumatic caster tire, any size,
replacement only, each Y

❂ E2385 Power wheelchair accessory, tube for pneumatic caster tire, any size,
replacement only, each Y

❂ E2386 Power wheelchair accessory, foam filled drive wheel tire, any size,
replacement only, each Y

❂ E2387 Power wheelchair accessory, foam filled caster tire, any size,
replacement only, each Y

❂ E2388 Power wheelchair accessory, foam drive wheel tire, any size,
replacement only, each Y

❂ E2389 Power wheelchair accessory, foam caster tire, any size, replacement
only, each Y

❂ E2390 Power wheelchair accessory, solid (rubber/plastic) drive wheel tire,

any size, replacement only, each Y

❂ E2391 Power wheelchair accessory, solid (rubber/plastic) caster tire

 (removable), any size, replacement only, each Y

❂ E2392 Power wheelchair accessory, solid (rubber/plastic) caster tire with

integrated wheel, any size, replacement only, each Y

❂ E2394 Power wheelchair accessory, drive wheel excludes tire, any size,
replacement only, each Y

❂ E2395 Power wheelchair accessory, caster wheel excludes tire, any size,
replacement only, each Y

❂ E2396 Power wheelchair accessory, caster fork, any size, replacement only,
each Y

✽ E2397 Power wheelchair accessory, lithium-based battery, each

Y
✽ E2398 Wheelchair accessory, dynamic positioning hardware for back Y

Negative Pressure
✽ E2402 Negative pressure wound therapy electrical pump, stationary or
portable Y

Document at least every 30 calendar days the quantitative wound

characteristics, including wound surface area (length, width and
depth).
Medicare coverage up to a maximum of 15 dressing kits (A6550)
per wound per month unless documentation states that the wound
size requires more than one dressing kit for each dressing change.

Speech Device
❂ E2500 Speech generating device, digitized speech, using pre-recorded
messages, less than or equal to 8 minutes recording time
Y
IOM: 100-03, 1, 50.1
❂ E2502 Speech generating device, digitized speech, using pre-recorded
messages, greater than 8 minutes but less than or equal to 20
minutes recording time Y

IOM: 100-03, 1, 50.1

❂ E2504 Speech generating device, digitized speech, using pre-recorded
messages, greater than 20 minutes but less than or equal to 40
minutes recording time Y

IOM: 100-03, 1, 50.1

❂ E2506 Speech generating device, digitized speech, using pre-recorded
messages, greater than 40 minutes recording time Y
 IOM: 100-03, 1, 50.1
❂ E2508 Speech generating device, synthesized speech, requiring message
formulation by spelling and access by physical contact with the
device Y

IOM: 100-03, 1, 50.1

❂ E2510 Speech generating device, synthesized speech, permitting multiple
methods of message formulation and multiple methods of device
access Y

IOM: 100-03, 1, 50.1

❂ E2511 Speech generating software program, for personal computer or
personal digital assistant Y

IOM: 100-03, 1, 50.1

❂ E2512 Accessory for speech generating device, mounting system
Y
IOM: 100-03, 1, 50.1
❂ E2599 Accessory for speech generating device, not otherwise classified
Y
IOM: 100-03, 1, 50.1

Wheelchair: Cushion
✽ E2601 General use wheelchair seat cushion, width less than 22 inches, any
depth Y

✽ E2602 General use wheelchair seat cushion, width 22 inches or greater, any
depth Y

✽ E2603 Skin protection wheelchair seat cushion, width less than 22 inches,
any depth Y

✽ E2604 Skin protection wheelchair seat cushion, width 22 inches or greater,

any depth Y

✽ E2605 Positioning wheelchair seat cushion, width less than 22 inches, any
depth Y

✽ E2606 Positioning wheelchair seat cushion, width 22 inches or greater, any

depth Y

✽ E2607 Skin protection and positioning wheelchair seat cushion, width less
than 22 inches, any depth Y

✽ E2608 Skin protection and positioning wheelchair seat cushion, width 22

inches or greater, any depth Y

✽ E2609 Custom fabricated wheelchair seat cushion, any size Y

✽ E2610 Wheelchair seat cushion, powered B

 ✽ E2611 General use wheelchair back cushion, width less than 22 inches, any
height, including any type mounting hardware Y

✽ E2612 General use wheelchair back cushion, width 22 inches or greater,

any height, including any type mounting hardware Y

✽ E2613 Positioning wheelchair back cushion, posterior, width less than 22

inches, any height, including any type mounting hardware
Y
✽ E2614 Positioning wheelchair back cushion, posterior, width 22 inches or
greater, any height, including any type mounting hardware
Y
✽ E2615 Positioning wheelchair back cushion, posterior-lateral, width less
than 22 inches, any height, including any type mounting hardware
Y

✽ E2616 Positioning wheelchair back cushion, posterior-lateral, width 22

inches or greater, any height, including any type mounting hardware
Y

✽ E2617 Custom fabricated wheelchair back cushion, any size, including any
type mounting hardware Y

✽ E2619 Replacement cover for wheelchair seat cushion or back cushion,

each Y

✽ E2620 Positioning wheelchair back cushion, planar back with lateral

supports, width less than 22 inches, any height, including any type
mounting hardware Y

✽ E2621 Positioning wheelchair back cushion, planar back with lateral

supports, width 22 inches or greater, any height, including any type
mounting hardware Y

Wheelchair: Skin Protection

✽ E2622 Skin protection wheelchair seat cushion, adjustable, width less than
22 inches, any depth Y

✽ E2623 Skin protection wheelchair seat cushion, adjustable, width 22 inches

or greater, any depth Y

✽ E2624 Skin protection and positioning wheelchair seat cushion, adjustable,

width less than 22 inches, any depth Y

✽ E2625 Skin protection and positioning wheelchair seat cushion, adjustable,

width 22 inches or greater, any depth Y

Wheelchair: Arm Support

 ✽ E2626 Wheelchair accessory, shoulder elbow, mobile arm support attached
to wheelchair, balanced, adjustable Y

✽ E2627 Wheelchair accessory, shoulder elbow, mobile arm support attached

to wheelchair, balanced, adjustable rancho type Y

✽ E2628 Wheelchair accessory, shoulder elbow, mobile arm support attached

to wheelchair, balanced, reclining Y

✽ E2629 Wheelchair accessory, shoulder elbow, mobile arm support attached

to wheelchair, balanced, friction arm support (friction dampening to
proximal and distal joints) Y

✽ E2630 Wheelchair accessory, shoulder elbow, mobile arm support,

monosuspension arm and hand support, overhead elbow forearm
hand sling support, yoke type suspension support Y

✽ E2631 Wheelchair accessory, addition to mobile arm support, elevating

proximal arm Y

✽ E2632 Wheelchair accessory, addition to mobile arm support, offset or

lateral rocker arm with elastic balance control Y

✽ E2633 Wheelchair accessory, addition to mobile arm support, supinator

Y

Pediatric Gait Trainer

E8000 Gait trainer, pediatric size, posterior support, includes all accessories
and components E1

E8001 Gait trainer, pediatric size, upright support, includes all accessories
and components E1

E8002 Gait trainer, pediatric size, anterior support, includes all accessories
and components E1

TEMPORARY PROCEDURES/PROFESSIONAL
SERVICES (G0000-G9999)
NOTE: Series “G”, “K”, and “Q” in the Level II coding are reserved for CMS
assignment. “G”, “K”, and “Q” codes are temporary national codes for items or
services requiring uniform national coding between one year’s update and the
next. Sometimes “temporary” codes remain for more than one update. If “G”,
“K”, and “Q” codes are not converted to permanent codes in Level I or Level II
series in the following update, they will remain active until converted in
following years or until CMS notifies contractors to delete them. All active “G”,
“K”, and “Q” codes at the time of update will be included on the update file for
contractors. In addition, deleted codes are retained on the file for informational
purposes, with a deleted indicator, for four years.

Vaccine Administration
✽ G0008 Administration of influenza virus vaccine S

Coinsurance and deductible do not apply. If provided, report

significant, separately identifiable E/M for medically necessary
services (Z23).
Coding Clinic: 2016, Q4, P3
✽ G0009 Administration of pneumococcal vaccine S

Reported once in a lifetime based on risk; Medicare covers cost of

vaccine and administration (Z23)
Copayment, coinsurance, and deductible waived.
(https://www.cms.gov/Outreach-and-Education/Medicare-Learning-
Network-
MLN/MLNProducts/Downloads/PreventiveServicesPoster.pdf)
Coding Clinic: 2016, Q4, P3
✽ G0010 Administration of hepatitis B vaccine S

Report for other than OPPs. Coinsurance and deductible apply;

Medicare covers both cost of vaccine and administration (Z23)
Copayment/coinsurance and deductible are waived.
(https://www.cms.gov/Outreach-and-Education/Medicare-Learning-
Network-
MLN/MLNProducts/Downloads/PreventiveServicesPoster.pdf)
Coding Clinic: 2016, Q4, P3

Semen Analysis
✽ G0027 Semen analysis; presence and/or motility of sperm excluding
Huhner ♂ Q4

Laboratory Certification: Hematology

G0028 Documentation of medical reason(s) for not screening for tobacco
use (e.g., limited life expectancy, other medical reason)
✽ G0029 Tobacco screening not performed or tobacco cessation intervention
not provided during the measurement period or in the six months
prior to the measurement period M

Patient screened for tobacco use and received tobacco cessation

✽ G0030 intervention during the measurement period or in the six months
prior to the measurement period (counseling, pharmacotherapy, or
both), if identified as a tobacco user M

✽ G0031 Palliative care services given to patient any time during the
measurement period M

✽ G0032 Two or more antipsychotic prescriptions ordered for patients who

had a diagnosis of schizophrenia, schizoaffective disorder, or bipolar
disorder on or between January 1 of the year prior to the
measurement period and the index prescription start date (ipsd) for
antipsychotics M

✽ G0033 Two or more benzodiazepine prescriptions ordered for patients who

had a diagnosis of seizure disorders, rapid eye movement sleep
behavior disorder, benzodiazepine withdrawal, ethanol withdrawal,
or severe generalized anxiety disorder on or between January 1 of
the year prior to the measurement period and the ipsd for
benzodiazepines M

✽ G0034 Patients receiving palliative care during the measurement period M

✽ G0035 Patient has any emergency department encounter during the
performance period with place of service indicator 23 M

✽ G0036 Patient or care partner decline assessment M

✽ G0037 On date of encounter, patient is not able to participate in assessment

or screening, including non-verbal patients, delirious, severely
aphasic, severely developmentally delayed, severe visual or hearing
impairment and for those patients, no knowledgeable informant
available M

✽ G0038 Clinician determines patient does not require referral M

✽ G0039 Patient not referred, reason not otherwise specified M

✽ G0040 Patient already receiving physical/occupational/speech/recreational

therapy during the measurement period M

✽ G0041 Patient and/or care partner decline referral M

✽ G0042 Referral to physical, occupational, speech, or recreational therapy

M
✽ G0043 Patients with mechanical prosthetic heart valve M

✽ G0044 Patients with moderate or severe mitral stenosis M

✽ G0045 Clinical follow-up and mrs score assessed at 90 days following

endovascular stroke intervention M

Clinical follow-up and mrs score not assessed at 90 days following

 ✽ G0046 endovascular stroke intervention M

✽ G0047 Pediatric patient with minor blunt head trauma and pecarn
prediction criteria are not assessed M

✽ G0048 Patients who receive palliative care services any time during the
intake period through the end of the measurement year M

✽ G0049 With maintenance hemodialysis (incenter and home hd) for the
complete reporting month M

✽ G0050 Patients with a catheter that have limited life expectancy M

✽ G0051 Patients under hospice care in the current reporting month M

✽ G0052 Patients on peritoneal dialysis for any portion of the reporting month
M
✽ G0053 Advancing rheumatology patient care mips value pathways M

✽ G0054 Coordinating stroke care to promote prevention and cultivate

positive outcomes mips value pathways M

✽ G0055 Advancing care for heart disease mips value pathways M

✽ G0056 Optimizing chronic disease management mips value pathways M

✽ G0057 Proposed adopting best practices and promoting patient safety

within emergency medicine mips value pathways M

✽ G0058 Improving care for lower extremity joint repair mips value pathways
M
✽ G0059 Patient safety and support of positive experiences with anesthesia
mips value pathways M

✽ G0060 Allergy/immunology mips specialty set M

✽ G0061 Anesthesiology mips specialty set M

✽ G0062 Audiology mips specialty set M

✽ G0063 Cardiology mips specialty set M

✽ G0064 Certified nurse midwife mips specialty set M

✽ G0065 Chiropractic medicine mips specialty set M

✽ G0066 Clinical social work mips specialty set M

✽ G0067 Dentistry mips specialty set M

Administration, Payment and Care Management Services

✽ G0068 Professional services for the administration of anti-infective, pain
management, chelation, pulmonary hypertension, or other
 intravenous infusion drug or biological (excluding chemotherapy or
other highly complex drug or biological) inotropic for each infusion
drug administration calendar day in the individual’s home, each 15
minutes A

✽ G0069 Professional services for the administration of subcutaneous

immunotherapy or other subcutaneous infusion drug or biological
for each infusion drug administration calendar day in the
individual’s home, each 15 minutes A

✽ G0070 Professional services for the administration of intravenous

chemotherapy or other intravenous highly complex drug or
biological infusion for each infusion drug administration calendar
day in the individual’s home, each 15 minutes A

✽ G0071 Payment for communication technology-based services for 5

minutes or more of a virtual (non-face-to-face) communication
between an rural health clinic (RHC) or federally qualified health
center (FQHC) practitioner and RHC or FQHC patient, or 5 minutes
or more of remote evaluation of recorded video and/or images by an
RHC or FQHC practitioner, occurring in lieu of an office visit; RHC
or FQHC only A

✽ G0076 Brief (20 minutes) care management home visit for a new patient.
For use only in a Medicare-approved CMMI model. (Services must
be furnished within a beneficiary’s home, domiciliary, rest home,
assisted living and/or nursing facility.) B

✽ G0077 Limited (30 minutes) care management home visit for a new patient.
For use only in a Medicare-approved CMMI model. (Services must
be furnished within a beneficiary’s home, domiciliary, rest home,
assisted living and/or nursing facility.) B

✽ G0078 Moderate (45 minutes) care management home visit for a new
patient. For use only in a Medicareapproved CMMI model.
(Services must be furnished within a beneficiary’s home,
domiciliary, rest home, assisted living and/or nursing facility.) B

✽ G0079 Comprehensive (60 minutes) care management home visit for a new
patient. For use only in a Medicareapproved CMMI model.
(Services must be furnished within a beneficiary’s home,
domiciliary, rest home, assisted living and/or nursing facility.) B

✽ G0080 Extensive (75 minutes) care management home visit for a new
patient. For use only in a Medicareapproved CMMI model.
(Services must be furnished within a beneficiary’s home,
domiciliary, rest home, assisted living and/or nursing facility.) B
✽ G0081 Brief (20 minutes) care management home visit for an existing
patient. For use only in a Medicare-approved CMMI model.
(Services must be furnished within a beneficiary’s home,
domiciliary, rest home, assisted living and/or nursing facility.) B

✽ G0082 Limited (30 minutes) care management home visit for an existing
patient. For use only in a Medicare-approved CMMI model.
(Services must be furnished within a beneficiary’s home,
domiciliary, rest home, assisted living and/or nursing facility.) B

✽ G0083 Moderate (45 minutes) care management home visit for an existing
patient. For use only in a Medicare-approved CMMI model.
(Services must be furnished within a beneficiary’s home,
domiciliary, rest home, assisted living and/or nursing facility.) B

✽ G0084 Comprehensive (60 minutes) care management home visit for an

existing patient. For use only in a Medicareapproved CMMI model.
(Services must be furnished within a beneficiary’s home,
domiciliary, rest home, assisted living and/or nursing facility.) B

✽ G0085 Extensive (75 minutes) care management home visit for an existing
patient. For use only in a Medicareapproved CMMI model.
(Services must be furnished within a beneficiary’s home,
domiciliary, rest home, assisted living and/or nursing facility.) B

✽ G0086 Limited (30 minutes) care management home care plan oversight.
For use only in a Medicare-approved CMMI model. (Services must
be furnished within a beneficiary’s home, domiciliary, rest home,
assisted living and/or nursing facility.) B

✽ G0087 Comprehensive (60 minutes) care management home care plan

oversight. For use only in a Medicare-approved CMMI model.
(Services must be furnished within a beneficiary’s home,
domiciliary, rest home, assisted living and/or nursing facility.) B

✽ G0088 Professional services, initial visit, for the administration of anti-

infective, pain management, chelation, pulmonary hypertension,
inotropic, or other intravenous infusion drug or biological
(excluding chemotherapy or other highly complex drug or
biological) for each infusion drug administration calendar day in the
individual’s home, each 15 minutes A

✽ G0089 Professional services, initial visit, for the administration of

subcutaneous immunotherapy or other subcutaneous infusion drug
or biological for each infusion drug administration calendar day in
the individual’s home, each 15 minutes A

✽ G0090 Professional services, initial visit, for the administration of

 intravenous chemotherapy or other highly complex infusion drug or
biological for each infusion drug administration calendar day in the
individual’s home, each 15 minutes A

Screening Services
❂ G0101 Cervical or vaginal cancer screening; pelvic and clinical breast
examination S

Covered once every two years and annually if high risk for
cervical/vaginal cancer, or if childbearing age patient has had an
abnormal Pap smear in preceding three years. High risk diagnosis,
Z77.9
Coding Clinic: 2002, Q4, P8
❂ G0102 Prostate cancer screening; digital rectal examination N

Covered annually by Medicare (Z12.5). Not separately payable with

an E/M code (99201-99499).
IOM: 100-02, 6, 10; 100-04, 4, 240; 100-04, 18, 50.1
❂ G0103 Prostate cancer screening; prostate specific antigen test (PSA)
A
Covered annually by Medicare (Z12.5)
IOM: 100-02, 6, 10; 100-04, 4, 240; 100-04, 18, 50
Laboratory Certification: Routine chemistry
❂ G0104 Colorectal cancer screening; flexible sigmoidoscopy T

Covered once every 48 months for beneficiaries age 50+

Co-insurance waived under Section 4104.
Coding Clinic: 2011, Q2, P4
❂ G0105 Colorectal cancer screening; colonoscopy on individual at high risk
T

Screening colonoscopy covered once every 24 months for high risk

for developing colorectal cancer. May use modifier 53 if appropriate
(physician fee schedule).
Co-insurance waived under Section 4104.
Coding Clinic: 2018, Q2, P4; 2011, Q2, P4
❂ G0106 Colorectal cancer screening; alternative to G0104, screening
sigmoidoscopy, barium enema S

Barium enema (not high risk) (alternative to G0104). Covered once

every 4 years for beneficiaries age 50+. Use modifier 26 for
professional component only.
 Coding Clinic: 2011, Q2, P4

Diabetes Management Training Services

✽ G0108 Diabetes outpatient self-management training services, individual,
per 30 minutes A

Report for beneficiaries diagnosed with diabetes.

Effective January 2011, DSMT will be included in the list of
reimbursable Medicare telehealth services.
✽ G0109 Diabetes outpatient self-management training services, group
session (2 or more) per 30 minutes A

Report for beneficiaries diagnosed with diabetes.

Effective January 2011, DSMT will be included in the list of
reimbursable Medicare telehealth services.

Screening Services
✽ G0117 Glaucoma screening for high risk patients furnished by an
optometrist or ophthalmologist S

Covered once per year (full 11 months between screenings).

Bundled with all other ophthalmic services provided on same day.
Diagnosis code Z13.5.
✽ G0118 Glaucoma screening for high risk patient furnished under the direct
supervision of an optometrist or ophthalmologist S

Covered once per year (full 11 months between screenings).

Diagnosis code Z13.5.
❂ G0120 Colorectal cancer screening; alternative to G0105, screening
colonoscopy, barium enema. S

Barium enema for patients with a high risk of developing colorectal.

Covered once every 2 years. Used as an alternative to G0105. Use
modifier 26 for professional component only.
❂ G0121 Colorectal cancer screening; colonoscopy on individual not meeting
criteria for high risk T

Screening colonoscopy for patients that are not high risk. Covered
once every 10 years, but not within 48 months of a G0104. For non-
Medicare patients report 45378.
Co-insurance waived under Section 4104.
Coding Clinic: 2018, Q2, P4
G0122 Colorectal cancer screening; barium enema E1
 Medicare: this service is denied as noncovered, because it fails to
meet the requirements of the benefit. The beneficiary is liable for
payment.
❂ G0123 Screening cytopathology, cervical or vaginal (any reporting system),
collected in preservative fluid, automated thin layer preparation,
screening by cytotechnologist under physician supervision
♀ A

Use G0123 or G0143 or G0144 or G0145 or G0147 or G0148 or

P3000 for Pap smears NOT requiring physician interpretation
(technical component).
IOM: 100-03, 3, 190.2; 100-04, 18, 30
Laboratory Certification: Cytology
❂ G0124 Screening cytopathology, cervical or vaginal (any reporting system),
collected in preservative fluid, automated thin layer preparation,
requiring interpretation by physician ♀ B

Report professional component for Pap smears requiring physician

interpretation.
IOM: 100-03, 3, 190.2; 100-04, 18, 30
Laboratory Certification: Cytology
Miscellaneous Services, Diagnostic and Therapeutic
❂ G0127 Trimming of dystrophic nails, any number Q1

Must be used with a modifier (Q7, Q8, or Q9) to show that the foot
care service is needed because the beneficiary has a systemic
disease. Limit 1 unit of service.
IOM: 100-02, 15, 290
❂ G0128 Direct (face-to-face with patient) skilled nursing services of a
registered nurse provided in a comprehensive outpatient
rehabilitation facility, each 10 minutes beyond the first 5 minutes
B

A separate nursing service that is clearly identifiable in the Plan of

Treatment and not part of other services. Documentation must
support this service. Examples include: Insertion of a urinary
catheter, intramuscular injections, bowel disimpaction, nursing
assessment, and education. Restricted coverage by Medicare.
Medicare Statute 1833(a)
✽ G0129 Occupational therapy services requiring the skills of a qualified
occupational therapist, furnished as a component of a partial
hospitalization treatment program, per session (45 minutes or more)
P

❂ G0130 Single energy x-ray absorptiometry (SEXA) bone density study, one
or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist,
heel) Z3 S

Covered every 24 months (more frequently if medically necessary).

Use modifier 26 for professional component only.
Preventive service; no deductible
IOM: 100-03, 2, 150.3; 100-04, 13, 140.1
✽ G0141 Screening cytopathology smears, cervical or vaginal, performed by
automated system, with manual rescreening, requiring interpretation
by physician ♀ B

Co-insurance, copay, and deductible waived

Report professional component for Pap smears requiring physician
interpretation. Refer to diagnosis of Z92.89, Z12.4, Z12.72, or
Z12.89 to report appropriate risk level.
Laboratory Certification: Cytology
✽ 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
physician supervision ♀ A

Co-insurance, copay, and deductible waived

Laboratory Certification: Cytology
✽ G0144 Screening cytopathology, cervical or vaginal (any reporting system),
collected in preservative fluid, automated thin layer preparation,
with screening by automated system, under physician supervision
♀ A

Co-insurance, copay, and deductible waived

Laboratory Certification: Cytology
✽ 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
physician supervision ♀ A

Co-insurance, copay, and deductible waived

Laboratory Certification: Cytology
✽ G0147 Screening cytopathology smears, cervical or vaginal; performed by
automated system under physician supervision ♀ A

Co-insurance, copay, and deductible waived

Laboratory Certification: Cytology
✽ G0148 Screening cytopathology smears, cervical or vaginal; performed by
automated system with manual rescreening ♀ A

Co-insurance, copay, and deductible waived

Laboratory Certification: Cytology
✽ G0151 Services performed by a qualified physical therapist in the home
health or hospice setting, each 15 minutes B

✽ G0152 Services performed by a qualified occupational therapist in the

home health or hospice setting, each 15 minutes B

✽ G0153 Services performed by a qualified speech-language pathologist in

the home health or hospice setting, each 15 minutes B

✽ G0155 Services of clinical social worker in home health or hospice settings,

each 15 minutes B

✽ G0156 Services of home health/health aide in home health or hospice

settings, each 15 minutes B

✽ G0157 Services performed by a qualified physical therapist assistant in the

home health or hospice setting, each 15 minutes B
 ✽ G0158 Services performed by a qualified occupational therapist assistant in
the home health or hospice setting, each 15 minutes B

✽ G0159 Services performed by a qualified physical therapist, in the home

health setting, in the establishment or delivery of a safe and
effective physical therapy maintenance program, each 15 minutes
B
✽ G0160 Services performed by a qualified occupational therapist, in the
home health setting, in the establishment or delivery of a safe and
effective occupational therapy maintenance program, each 15
minutes B

✽ G0161 Services performed by a qualified speech-language pathologist, in

the home health setting, in the establishment or delivery of a safe
and effective speech-language pathology maintenance program,
each 15 minutes B

✽ G0162 Skilled services by a registered nurse (RN) for management and

evaluation of the plan of care; each 15 minutes (the patient’s
underlying condition or complication requires an RN to ensure that
essential non-skilled care achieves its purpose in the home health or
hospice setting) B

Transmittal No. 824 (CR7182)

❂ G0166 External counterpulsation, per treatment session Q1

IOM: 100-03, 1, 20.20

✽ G0168 Wound closure utilizing tissue adhesive(s) only B

Report for wound closure with only tissue adhesive. If a practitioner

utilizes tissue adhesive in addition to staples or sutures to close a
wound, HCPCS code G0168 is not separately reportable, but is
included in the tissue repair.
The only closure material used for a simple repair, coverage based
on payer.
Coding Clinic: 2005, Q1, P5; 2001, Q4, P12; Q3, P13

Figure 15 Tissue adhesive.

✽ G0175 Scheduled interdisciplinary team conference (minimum of three
exclusive of patient care nursing staff) with patient present
V
❂ G0176 Activity therapy, such as music, dance, art or play therapies not for
recreation, related to the care and treatment of patient’s disabling
mental health problems, per session (45 minutes or more) P

Paid in partial hospitalization

❂ G0177 Training and educational services related to the care and treatment
of patient’s disabling mental health problems per session (45
minutes or more) N

Paid in partial hospitalization

✽ G0179 Physician recertification for Medicare-covered home health services
under a home health plan of care (patient not present), including
contacts with home health agency and review of reports of patient
status required by physicians to affirm the initial implementation of
the plan of care that meets patient’s needs, per recertification period
M

The recertification code is used after a patient has received services

for at least 60 days (or one certification period) when the physician
signs the certification after the initial certification period.
✽ G0180 Physician certification for Medicare-covered home health services
under a home health plan of care (patient not present), including
contacts with home health agency and review of reports of patient
status required by physicians to affirm the initial implementation of
the plan of care that meets patient’s needs, per certification period
M

This code can be billed only when the patient has not received
Medicare covered home health services for at least 60 days.
✽ G0181 Physician supervision of a patient receiving Medicare-covered
services provided by a participating home health agency (patient not
present) requiring complex and multidisciplinary care modalities
involving regular physician development and/or revision of care
plans, review of subsequent reports of patient status, review of
laboratory and other studies, communication (including telephone
calls) with other health care professionals involved in the patient’s
care, integration of new information into the medical treatment plan
and/or adjustment of medical therapy, within a calendar month, 30
minutes or more M
Coding Clinic: 2015, Q2, P10
Figure 16 PET scan.

✽ G0182 Physician supervision of a patient under a Medicare-approved

hospice (patient not present) requiring complex and
multidisciplinary care modalities involving regular physician
development and/or revision of care plans, review of subsequent
reports of patient status, review of laboratory and other studies,
communication (including telephone calls) with other health care
professionals involved in the patient’s care, integration of new
information into the medical treatment plan and/or adjustment of
medical therapy, within a calendar month, 30 minutes or more
M
Coding Clinic: 2015, Q2, P10
✽ G0186 Destruction of localized lesion of choroid (for example, choroidal
neovascularization); photocoagulation, feeder vessel technique (one
or more sessions) T

G0219 PET imaging whole body; melanoma for non-covered indications

E1
Example: Assessing regional lymph nodes in melanoma.
IOM: 100-03, 4, 220.6
Coding Clinic: 2007, Q1, P6
G0235 PET imaging, any site, not otherwise specified E1

Example: Prostate cancer diagnosis and initial staging.

IOM: 100-03, 4, 220.6
Coding Clinic: 2007, Q1, P6
✽ G0237 Therapeutic procedures to increase strength or endurance of
respiratory muscles, face to face, one on one, each 15 minutes
(includes monitoring) S

✽ G0238 Therapeutic procedures to improve respiratory function, other than

described by G0237, one on one, face to face, per 15 minutes
(includes monitoring) S

✽ G0239 Therapeutic procedures to improve respiratory function or increase

strength or endurance of respiratory muscles, two or more
individuals (includes monitoring) S
❂ G0245 Initial physician evaluation and management of a diabetic patient
with diabetic sensory neuropathy resulting in a loss of protective
sensation (LOPS) which must include (1) the diagnosis of LOPS,
(2) a patient history, (3) a physical examination that consist of at
least the following elements: (A) visual inspection of the forefoot,
hindfoot and toe web spaces, (B) evaluation of a protective
sensation, (C) evaluation of foot structure and biomechanics, (D)
evaluation of vascular status and skin integrity, and (E) evaluation
and recommendation of footwear, and (4) patient education
V
IOM: 100-03, 1, 70.2.1
❂ G0246 Follow-up physician evaluation and management of a diabetic
patient with diabetic sensory neuropathy resulting in a loss of
protective sensation (LOPS) to include at least the following: (1) a
patient history, (2) a physical examination that includes: (A) visual
inspection of the forefoot, hindfoot and toe web spaces, (B)
evaluation of protective sensation, (C) evaluation of foot structure
and biomechanics, (D) evaluation of vascular status and skin
integrity, and (E) evaluation and recommendation of footwear, and
(3) patient education V

IOM: 100-03, 1, 70.2.1; 100-02, 15, 290

❂ G0247 Routine foot care by a physician of a diabetic patient with diabetic
sensory neuropathy resulting in a loss of protective sensation
(LOPS) to include, the local care of superficial wounds (i.e.,
superficial to muscle and fascia) and at least the following if
present: (1) local care of superficial wounds, (2) debridement of
corns and calluses, and (3) trimming and debridement of nails
Q1
IOM: 100-03, 1, 70.2.1
❂ G0248 Demonstration, prior to initiation, of home INR monitoring for
patient with either mechanical heart valve(s), chronic atrial
fibrillation, or venous thromboembolism who meets Medicare
coverage criteria, under the direction of a physician; includes: face-
to-face demonstration of use and care of the INR monitor, obtaining
at least one blood sample, provision of instructions for reporting
home INR test results, and documentation of patient’s ability to
perform testing and report results V

❂ G0249 Provision of test materials and equipment for home INR monitoring
of patient with either mechanical heart valve(s), chronic atrial
fibrillation, or venous thromboembolism who meets Medicare
coverage criteria; includes provision of materials for use in the
 home and reporting of test results to physician; testing not occurring
more frequently than once a week; testing materials, billing units of
service include 4 tests V

❂ G0250 Physician review, interpretation, and patient management of home

INR testing for patient with either mechanical heart valve(s),
chronic atrial fibrillation, or venous thromboembolism who meets
Medicare coverage criteria; testing not occurring more frequently
than once a week; billing units of service include 4 tests M

G0252 PET imaging, full and partial-ring PET scanners only, for initial
diagnosis of breast cancer and/or surgical planning for breast cancer
(e.g., initial staging of axillary lymph nodes) E1

IOM: 100-03, 4, 220.6

Coding Clinic: 2007, Q1, P6
G0255 Current perception threshold/sensory nerve conduction test (SNCT),
per limb, any nerve E1

IOM: 100-03, 2, 160.23

❂ G0257 Unscheduled or emergency dialysis treatment for an ESRD patient
in a hospital outpatient department that is not certified as an ESRD
facility S
Coding Clinic: 2003, Q1, P9
❂ G0259 Injection procedure for sacroiliac joint; arthrography N

Replaces 27096 for reporting injections for Medicare beneficiaries

Used by Part A only (facility), not priced by Part B Medicare.
❂ G0260 Injection procedure for sacroiliac joint; provision of anesthetic,
steroid and/or other therapeutic agent, with or without arthrography
T

ASCs report when a therapeutic sacroiliac joint injection is

administered in ASC
✽ G0268 Removal of impacted cerumen (one or both ears) by physician on
same date of service as audiologic function testing N

Report only when a physician, not an audiologist, performs the

procedure.
Use with DX H61.2- when performed by physician.
Coding Clinic: 2016, Q2, P2-3; 2003, Q1, P12
❂ G0269 Placement of occlusive device into either a venous or arterial access
site, post surgical or interventional procedure (e.g., angioseal plug,
vascular plug) N

Report for replacement of vasoseal. Hospitals may report the closure

 device as a supply with C1760. Bundled status on Physician Fee
Schedule.
Coding Clinic: 2011, Q3, P4; 2010, Q4, P6
✽ G0270 Medical nutrition therapy; reassessment and subsequent
intervention(s) following second referral in same year for change in
diagnosis, medical condition or treatment regimen (including
additional hours needed for renal disease), individual, face to face
with the patient, each 15 minutes A

Requires physician referral for beneficiaries with diabetes or renal

disease. Services must be provided by dietitian/nutritionist. Co-
insurance and deductible waived.
✽ G0271 Medical nutrition therapy, reassessment and subsequent
intervention(s) following second referral in same year for change in
diagnosis, medical condition, or treatment regimen (including
additional hours needed for renal disease), group (2 or more
individuals), each 30 minutes A

Requires physician referral for beneficiaries with diabetes or renal

disease. Services must be provided by dietitian/nutritionist. Co-
insurance and deductible waived.
❂ G0276 Blinded procedure for lumbar stenosis, percutaneous image-guided
lumbar decompression (PILD) or placebocontrol, performed in an
approved coverage with evidence development (CED) clinical trial
J1

❂ G0277 Hyperbaric oxygen under pressure, full body chamber, per 30

minute interval S

IOM: 100-03, 1, 20.29

Coding Clinic: 2015, Q3, P7
✽ G0278 Iliac and/or femoral artery angiography, non-selective, bilateral or
ipsilateral to catheter insertion, performed at the same time as
cardiac catheterization and/or coronary angiography, includes
positioning or placement of the catheter in the distal aorta or
ipsilateral femoral or iliac artery, injection of dye, production of
permanent images, and radiologic supervision and interpretation
(list separately in addition to primary procedure) N

Medicare specific code not reported for iliac injection used as a

guiding shot for a closure device
Coding Clinic: 2011, Q3, P4; 2006, Q4, P7
✽ G0279 Diagnostic digital breast tomosynthesis, unilateral or bilateral (list
separately in addition to 77065 or 77066) A
✽ G0281 Electrical stimulation, (unattended), to one or more areas, for
chronic stage III and stage IV pressure ulcers, arterial ulcers,
diabetic ulcers, and venous stasis ulcers not demonstrating
measurable signs of healing after 30 days of conventional care, as
part of a therapy plan of care A

Reported by encounter/areas and not by site. Therapists report

.

G0281 and G0283 rather than 97014.

G0282 Electrical stimulation, (unattended), to one or more areas, for wound
care other than described in G0281 E1

IOM: 100-03, 4, 270.1

✽ G0283 Electrical stimulation (unattended), to one or more areas for
indication(s) other than wound care, as part of a therapy plan of care
A

Reported by encounter/areas and not by site. Therapists report

G0281 and G0283 rather than 97014.
✽ G0288 Reconstruction, computed tomographic angiography of aorta for
surgical planning for vascular surgery N

✽ G0289 Arthroscopy, knee, surgical, for removal of loose body, foreign

body, debridement/shaving of articular cartilage (chondroplasty) at
the time of other surgical knee arthroscopy in a different
compartment of the same knee N

Add-on code reported with knee arthroscopy code for major

procedure performed-reported once per extra compartment
“The code may be reported twice (or with a unit of two) if the
physician performs these procedures in two compartments, in
addition to the compartment where the main procedure was
performed.”
(https://www.aaos.org/aaosnow/2010/May/managing/managing2/?
ssopc=1)
❂ G0293 Noncovered surgical procedure(s) using conscious sedation,
regional, general or spinal anesthesia in a Medicare qualifying
clinical trial, per day Q1

❂ G0294 Noncovered procedure(s) using either no anesthesia or local

anesthesia only, in a Medicare qualifying clinical trial, per day
Q1
G0295 Electromagnetic therapy, to one or more areas, for wound care other
than described in G0329 or for other uses E1

IOM: 100-03, 4, 270.1

Counseling visit to discuss need for lung cancer screening (LDCT)
✽ G0296 using low dose CT scan (service is for eligibility determination and
shared decision making) S

✽ G0299 Direct skilled nursing services of a registered nurse (RN) in the

home health or hospice setting, each 15 minutes B

✽ G0300 Direct skilled nursing services of a licensed practical nurse (LPN) in

the home health or hospice setting, each 15 minutes B

✽ G0302 Pre-operative pulmonary surgery services for preparation for LVRS,

complete course of services, to include a minimum of 16 days of
services S

✽ G0303 Pre-operative pulmonary surgery services for preparation for LVRS,

10 to 15 days of services S

✽ G0304 Pre-operative pulmonary surgery services for preparation for LVRS,

1 to 9 days of services S

✽ G0305 Post-discharge pulmonary surgery services after LVRS, minimum of

6 days of services S

✽ G0306 Complete CBC, automated (HgB, HCT, RBC, WBC, without

platelet count) and automated WBC differential count Q4

Laboratory Certification: Hematology

✽ G0307 Complete CBC, automated (HgB, HCT, RBC, WBC; without
platelet count) Q4

Laboratory Certification: Hematology

▶ G0310 Immunization counseling by a physician or other qualified health
care professional when the vaccine(s) is not administered on the
same date of service, 5 to 15 mins time (this code is used for
Medicaid billing purposes)
▶ G0311 Immunization counseling by a physician or other qualified health
care professional when the vaccine(s) is not administered on the
same date of service, 16-30 mins time (this code is used for
Medicaid billing purposes)
▶ G0312 Immunization counseling by a physician or other qualify ED health
care professional when the vaccine(s) is not administered on the
same date of service for ages under 21, 5 to 15 mins time (this code
is used for Medicaid billing purposes)
▶ G0313 Immunization counseling by a physician or other qualified health
care professional when the vaccine(s) is not administered on the
same date of service for ages under 21, 16-30 mins time (this code is
used for Medicaid billing purposes)
▶ G0314 Immunization counseling by a physician or other qualified health
 care professional for covid-19, ages under 21, 16-30 mins time (this
code is used for the medicaid early and periodic screening,
diagnostic, and treatment benefit [EPSDT])
▶ G0315 Immunization counseling by a physician or other qualified health
care professional for covid-19, ages under 21, 5-15 mins time (this
code is used for the medicaid early and periodic screening,
diagnostic, and treatment benefit [EPSDT])
▶ G0316 Prolonged hospital inpatient or observation care evaluation and
management service(s) beyond the total time for the primary service
(when the primary service has been selected using time on the date
of the primary service); each additional 15 minutes by the physician
or qualified healthcare professional, with or without direct patient
contact (list separately in addition to CPT codes 99223, 99233, and
99236 for hospital inpatient or observation care evaluation and
management services). (do not report G0316 on the same date of
service as other prolonged services for evaluation and management
99358, 99359, 99418, 99415, 99416). (do not report G0316 for any
time unit less than 15 minutes) N

▶ G0317 Prolonged nursing facility evaluation and management service(s)

beyond the total time for the primary service (when the primary
service has been selected using time on the date of the primary
service); each additional 15 minutes by the physician or qualified
healthcare professional, with or without direct patient contact (list
separately in addition to CPT codes 99306, 99310 for nursing
facility evaluation and management services). (do not report G0317
on the same date of service as other prolonged services for
evaluation and management 99358, 99359, 99418). (do not report
G0317 for any time unit less than 15 minutes) B

▶ G0318 Prolonged home or residence evaluation and management service(s)

beyond the total time for the primary service (when the primary
service has been selected using time on the date of the primary
service); each additional 15 minutes by the physician or qualified
healthcare professional, with or without direct patient contact (list
separately in addition to CPT codes 99345, 99350 for home or
residence evaluation and management services). (do not report
G0318 on the same date of service as other prolonged services for
evaluation and management 99358, 99359, 99417). (do not report
G0318 for any time unit less than 15 minutes) B

▶ G0320 Home health services furnished using synchronous telemedicine

rendered via a real-time two-way audio and video
 telecommunications system A

▶ G0321 Home health services furnished using synchronous telemedicine

rendered via telephone or other real-time interactive audio-only
telecommunications system A

▶ G0322 The collection of physiologic data digitally stored and/or transmitted

by the patient to the home health agency (i.e., remote patient
monitoring) A

▶ G0323 Care management services for behavioral health conditions, at least

20 minutes of clinical psychologist or clinical social worker time,
per calendar month. (these services include the following required
elements: initial assessment or follow-up monitoring, including the
use of applicable validated rating scales; behavioral health care
planning in relation to behavioral/psychiatric health problems,
including revision for patients who are not progressing or whose
status changes; facilitating and coordinating treatment such as
psychotherapy, coordination with and/or referral to physicians and
practitioners who are authorized by Medicare to prescribe
medications and furnish e/m services, counseling and/or psychiatric
consultation; and continuity of care with a designated member of the
care team) S

✽ G0327 Colorectal cancer screening; blood-based biomarker A

Figure 17 Electromagnetic device.

❂ G0328 Colorectal cancer screening; fecal occult blood test, immunoassay,

1-3 simultaneous A

Co-insurance and deductible waived

Reported for Medicare patients 501; one FOBT per year, with either
G0107 (guaiac-based) or G0328 (immunoassay-based)
 Laboratory Certification: Routine chemistry, Hematology
Coding Clinic: 2012, Q2, P9
✽ G0329 Electromagnetic therapy, to one or more areas for chronic stage III
and stage IV pressure ulcers, arterial ulcers, and diabetic ulcers and
venous stasis ulcers not demonstrating measurable signs of healing
after 30 days of conventional care as part of a therapy plan of care
A

▶ G0330 Facility services for dental rehabilitation procedure(s) performed on

a patient who requires monitored anesthesia (e.g., general,
intravenous sedation (monitored anesthesia care) and use of an
operating room S

❂ G0333 Pharmacy dispensing fee for inhalation drug(s); initial 30-day

supply as a beneficiary M

Medicare will reimburse an initial dispensing fee to a pharmacy for

initial 30-day period of inhalation drugs furnished through DME.
✽ G0337 Hospice evaluation and counseling services, pre-election
B
✽ G0339 Image-guided robotic linear accelerator-based stereotactic
radiosurgery, complete course of therapy in one session or first
session of fractionated treatment B

✽ G0340 Image-guided robotic linear accelerator-based stereotactic

radiosurgery, delivery including collimator changes and custom
plugging, fractionated treatment, all lesions, per session, second
through fifth sessions, maximum five sessions per course of
treatment B

❂ G0341 Percutaneous islet cell transplant, includes portal vein

catheterization and infusion C

IOM: 100-03, 4, 260.3; 100-04, 32, 70

❂ G0342 Laparoscopy for islet cell transplant, includes portal vein
catheterization and infusion C

IOM: 100-03, 4, 260.3

❂ G0343 Laparotomy for islet cell transplant, includes portal vein
catheterization and infusion C

IOM: 100-03, 4, 260.3

❂ G0372 Physician service required to establish and document the need for a
power mobility device M

Providers should bill the E/M code and G0372 on the same claim.

Hospital Services: Observation and Emergency Department

❂ G0378 Hospital observation service, per hour N

Report all related services in addition to G0378. Report units of

hours spent in observation (rounded to the nearest hour). Hospitals
report the ED or clinic visit with a CPT code or, if applicable,
G0379 (direct admit to observation) and G0378 (hospital
observation services, per hour).
Coding Clinic: 2007, Q1, P10; 2006, Q3, P7-8
❂ G0379 Direct admission of patient for hospital observation care
Report all related services in addition to G0379. Report units of J2
hours spent in observation (rounded to the nearest hour). Hospitals
report the ED or clinic visit with a CPT code or, if applicable,
G0379 (direct admit to observation) and G0378 (hospital
observation services, per hour).
Coding Clinic: 2007, Q1, P7
✽ G0380 Level 1 hospital emergency department visit provided in a type B
emergency department; (the ED must meet at least one of the
following requirements: (1) it is licensed by the state in which it is
located under applicable state law as an emergency room or
emergency department; (2) it is held out to the public (by name,
posted signs, advertising, or other means) as a place that provides
care for emergency medical conditions on an urgent basis without
requiring a previously scheduled appointment; or (3) during the
calendar year immediately preceding the calendar year in which a
determination under 42 CFR 489.24 is being made, based on a
representative sample of patient visits that occurred during that
calendar year, it provides at least one-third of all of its outpatient
visits for the treatment of emergency medical conditions on an
urgent basis without requiring a previously scheduled appointment)
J2
Coding Clinic: 2009, Q1, P4; 2007, Q2, P1
✽ G0381 Level 2 hospital emergency department visit provided in a type B
emergency department; (the ED must meet at least one of the
following requirements: (1) it is licensed by the state in which it is
located under applicable state law as an emergency room or
emergency department; (2) it is held out to the public (by name,
posted signs, advertising, or other means) as a place that provides
care for emergency medical conditions on an urgent basis without
requiring a previously scheduled appointment; or (3) during the
calendar year immediately preceding the calendar year in which a
determination under 42 CFR 489.24 is being made, based on a
 representative sample of patient visits that occurred during that
calendar year, it provides at least one-third of all of its outpatient
visits for the treatment of emergency medical conditions on an
urgent basis without requiring a previously scheduled appointment)
J2
Coding Clinic: 2009, Q1, P4; 2007, Q2, P1
✽ G0382 Level 3 hospital emergency department visit provided in a type B
emergency department; (the ED must meet at least one of the
following requirements: (1) it is licensed by the state in which it is
located under applicable state law as an emergency room or
emergency department; (2) it is held out to the public (by name,
posted signs, advertising, or other means) as a place that provides
care for emergency medical conditions on an urgent basis without
requiring a previously scheduled appointment; or (3) during the
calendar year immediately preceding the calendar year in which a
determination under 42 CFR 489.24 is being made, based on a
representative sample of patient visits that occurred during that
calendar year, it provides at least one-third of all of its outpatient
visits for the treatment of emergency medical conditions on an
urgent basis without requiring a previously scheduled appointment)
J2
Coding Clinic: 2009, Q1, P4; 2007, Q2, P1
✽ G0383 Level 4 hospital emergency department visit provided in a type B
emergency department; (the ED must meet at least one of the
following requirements: (1) it is licensed by the state in which it is
located under applicable state law as an emergency room or
emergency department; (2) it is held out to the public (by name,
posted signs, advertising, or other means) as a place that provides
care for emergency medical conditions on an urgent basis without
requiring a previously scheduled appointment; or (3) during the
calendar year immediately preceding the calendar year in which a
determination under 42 CFR 489.24 is being made, based on a
representative sample of patient visits that occurred during that
calendar year, it provides at least one-third of all of its outpatient
visits for the treatment of emergency medical conditions on an
urgent basis without requiring a previously scheduled appointment)
J2
Coding Clinic: 2009, Q1, P4; 2007, Q2, P1
✽ G0384 Level 5 hospital emergency department visit provided in a type B
emergency department; (the ED must meet at least one of the
following requirements: (1) it is licensed by the state in which it is
 located under applicable state law as an emergency room or
emergency department; (2) it is held out to the public (by name,
posted signs, advertising, or other means) as a place that provides
care for emergency medical conditions on an urgent basis without
requiring a previously scheduled appointment; or (3) during the
calendar year immediately preceding the calendar year in which a
determination under 42 CFR 489.24 is being made, based on a
representative sample of patient visits that occurred during that
calendar year, it provides at least one-third of all of its outpatient
visits for the treatment of emergency medical conditions on an
urgent basis without requiring a previously scheduled appointment)
J2
Coding Clinic: 2009, Q1, P4; 2007, Q2, P1

Trauma Response Team

❂ G0390 Trauma response team associated with hospital critical care service
S
Coding Clinic: 2007, Q2, P5

Alcohol Substance Abuse Assessment and Intervention

✽ G0396 Alcohol and/or substance (other than tobacco) misuse structured
assessment (e.g., audit) and brief intervention 15 to 30 minutes
S
Bill instead of 99408 and 99409
✽ G0397 Alcohol and/or substance (other than tobacco) misuse structured
assessment (e.g., audit) and intervention, greater than 30 minutes
S

Bill instead of 99408 and 99409

Home Sleep Study Test

✽ G0398 Home sleep study test (HST) with type II portable monitor,
unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart
rate, airflow, respiratory effort and oxygen saturation S

✽ G0399 Home sleep test (HST) with type III portable monitor, unattended;
minimum of 4 channels: 2 respiratory movement/airflow, 1
ECG/heart rate and 1 oxygen saturation S

✽ G0400 Home sleep test (HST) with type IV portable monitor, unattended;
minimum of 3 channels S
Initial Examination for Medicare Enrollment
✽ G0402 Initial preventive physical examination; face-to-face visit, services
limited to new beneficiary during the first 12 months of Medicare
enrollment V

Depending on circumstances, 99201-99215 may be assigned with

modifier 25 to report an E/M service as a significant, separately
identifiable service in addition to the Initial Preventive Physical
Examination (IPPE), G0402.
Copayment and coinsurance waived, deductible waived.
Coding Clinic: 2009, Q4, P8

Electrocardiogram
✽ G0403 Electrocardiogram, routine ECG with 12 leads; performed as a
screening for the initial preventive physical examination with
interpretation and report M

Optional service may be ordered or performed at discretion of

physician. Once in a life-time screening, stemming from a referral
from Initial Preventive Physical Examination (IPPE). Both
deductible and co-payment apply.
✽ G0404 Electrocardiogram, routine ECG with 12 leads; tracing only, without
interpretation and report, performed as a screening for the initial
preventive physical examination S

✽ G0405 Electrocardiogram, routine ECG with 12 leads; interpretation and

report only, performed as a screening for the initial preventive
physical examination B

Follow-up Telehealth Consultation

✽ G0406 Follow-up inpatient consultation, limited, physicians typically spend
15 minutes communicating with the patient via telehealth
These telehealth modifers are required when billing for telehealth B
services with codes G0406-G0408 and G0425-G0427:
• GT, via interactive audio and video telecommunications system
• GQ, via asynchronous telecommunications system
✽ G0407 Follow-up inpatient consultation, intermediate, physicians typically
spend 25 minutes communicating with the patient via telehealth
B

✽ G0408 Follow-up inpatient consultation, complex, physicians typically

 spend 35 minutes communicating with the patient via telehealth
B

Psychological Services
✽ G0409 Social work and psychological services, directly relating to and/or
furthering the patient’s rehabilitation goals, each 15 minutes, face-
to-face; individual (services provided by a CORF-qualified social
worker or psychologist in a CORF) B

✽ G0410 Group psychotherapy other than of a multiple-family group, in a

partial hospitalization setting, approximately 45 to 50 minutes
P
Coding Clinic: 2009, Q4, P9, 10
✽ G0411 Interactive group psychotherapy, in a partial hospitalization setting,
approximately 45 to 50 minutes P
Coding Clinic: 2009, Q4, P9, 10

Fracture Treatment
✽ G0412 Open treatment of iliac spine(s), tuberosity avulsion, or iliac wing
fracture(s), unilateral or bilateral for pelvic bone fracture patterns
which do not disrupt the pelvic ring, includes internal fixation, when
performed C

✽ G0413 Percutaneous skeletal fixation of posterior pelvic bone fracture

and/or dislocation, for fracture patterns which disrupt the pelvic
ring, unilateral or bilateral, (includes ilium, sacroiliac joint and/or
sacrum) J1

✽ G0414 Open treatment of anterior pelvic bone fracture and/or dislocation

for fracture patterns which disrupt the pelvic ring, unilateral or
bilateral, includes internal fixation when performed (includes pubic
symphysis and/or superior/inferior rami) C

✽ G0415 Open treatment of posterior pelvic bone fracture and/or dislocation,

for fracture patterns which disrupt the pelvic ring, unilateral or
bilateral, includes internal fixation, when performed (includes ilium,
sacroiliac joint and/or sacrum) C

Surgical Pathology: Prostate Biopsy

✽ G0416 Surgical pathology, gross and microscopic examinations for prostate
needle biopsy, any method ♂ Q2

This testing requires a facility to have either a CLIA certificate of

 registration (certificate type code 9), a CLIA certificate of
compliance (certificate type code 1), or a CLIA certificate of
accreditation (certificate type code 3). A facility without a valid,
current, CLIA certificate, with a current CLIA certificate of waiver
(certificate type code 2) or with a current CLIA certificate for
provider-performed microscopy procedures (certificate type code 4),
must not be permitted to be paid for these tests. This code has a TC,
26 (physician), or global component.
Laboratory Certification: Histopathology
Coding Clinic: 2013, Q2, P6

Educational Services
✽ G0420 Face-to-face educational services related to the care of chronic
kidney disease; individual, per session, per one hour A

CKD is kidney damage of 3 months or longer, regardless of the

cause of kidney damage. Sessions billed in increments of one hour
(if session is less than one hour, it must last at least 31 minutes to be
billable. Sessions less than one hour and longer than 31 minutes are
billable as one session. No more than 6 sessions of KDE services in
a beneficiary’s lifetime.
✽ G0421 Face-to-face educational services related to the care of chronic
kidney disease; group, per session, per one hour A

Group setting: 2 to 20, report codes G0420 and G0421 with

diagnosis code N18.4.

Cardiac and Pulmonary Rehabilitation

✽ G0422 Intensive cardiac rehabilitation; with or without continuous ECG
monitoring with exercise, per session S

Includes the same service as 93798 but at a greater frequency; may

be reported with as many as six hourly sessions on a single date of
service. Includes medical nutrition services to reduce cardiac
disease risk factors.
✽ G0423 Intensive cardiac rehabilitation; with or without continuous ECG
monitoring; without exercise, per session S

Includes the same service as 93797 but at a greater frequency; may

be reported with as many as six hourly sessions on a single date of
service. Includes medical nutrition services to reduce cardiac
disease risk factors.
Initial Telehealth Consultation
✽ G0425 Telehealth consultation, emergency department or initial inpatient,
typically 30 minutes communicating with the patient via telehealth
B

Problem Focused: Problem focused history and examination, with

straightforward medical decision-making complexity. Typically 30
minutes communicating with patient via telehealth.
✽ G0426 Initial inpatient telehealth consultation, emergency department or
initial inpatient, typically 50 minutes communicating with the
patient via telehealth B

Detailed: Detailed history and examination, with moderate medical

decision-making complexity. Typically 50 minutes communicating
with patient via telehealth.
✽ G0427 Initial inpatient telehealth consultation, emergency department or
initial inpatient, typically 70 minutes or more communicating with
the patient via telehealth B

Comprehensive: Comprehensive history and examination, with high

medical decision-making complexity. Typically 70 minutes or more
communicating with patient via telehealth.

Fillers
G0428 Collagen meniscus implant procedure for filling meniscal defects
(e.g., cmi, collagen scaffold, menaflex) E1

✽ G0429 Dermal filler injection(s) for the treatment of facial lipodystrophy

syndrome (LDS) (e.g., as a result of highly active antiretroviral
therapy) T

Designated for dermal fillers Sculptra and Radiesse (Medicare).

(https://www.cms.gov/Regulations-and-
Guidance/Guidance/Transmittals/Downloads/R122NCD.pdf)
Coding Clinic: 2010, Q3, P8

Laboratory Screening
✽ G0432 Infectious agent antibody detection by enzyme immunoassay (EIA)
technique, HIV-1 and/or HIV-2, screening A

Laboratory Certification: Virology, General immunology

Coding Clinic: 2010, Q2, P10
✽ G0433 Infectious agent antibody detection by enzyme-linked
immunosorbent assay (ELISA) technique, HIV-1 and/or HIV-2,
 screening A

Laboratory Certification: Virology, General immunology

Coding Clinic: 2010, Q2, P10
✽ G0435 Infectious agent antibody detection by rapid antibody test, HIV-1
and/or HIV-2, screening A
Coding Clinic: 2010, Q2, P10

Counselling, Wellness, and Screening Services

✽ G0438 Annual wellness visit; includes a personalized prevention plan of
service (pps), initial visit A

✽ G0439 Annual wellness visit, includes a personalized prevention plan of

service (pps), subsequent visit A

✽ G0442 Annual alcohol misuse screening, 5 to 15 minutes S

Coding Clinic: 2012, Q1, P7
✽ G0443 Brief face-to-face behavioral counseling for alcohol misuse, 15
minutes S
Coding Clinic: 2012, Q1, P7
✽ G0444 Annual depression screening, 5 to 15 minutes S

✽ G0445 High intensity behavioral counseling to prevent sexually transmitted

infection; face-to-face, individual, includes: education, skills
training and guidance on how to change sexual behavior; performed
semi-annually, 30 minutes S

✽ G0446 Annual, face-to-face intensive behavioral therapy for cardiovascular

disease, individual, 15 minutes S
Coding Clinic: 2012, Q2, P8
✽ G0447 Face-to-face behavioral counseling for obesity, 15 minutes
Coding Clinic: 2012, Q1, P8 S

✽ G0448 Insertion or replacement of a permanent pacing cardioverter-

defibrillator system with transvenous lead(s), single or dual chamber
with insertion of pacing electrode, cardiac venous system, for left
ventricular pacing B

✽ G0451 Development testing, with interpretation and report, per

standardized instrument form Q3

Miscellaneous Services
✽ G0452 Molecular pathology procedure; physician interpretation and report
B

✽ G0453 Continuous intraoperative neurophysiology monitoring, from

 outside the operating room (remote or nearby), per patient (attention
directed exclusively to one patient), each 15 minutes (list in addition
to primary procedure) N

✽ G0454 Physician documentation of face-to-face visit for durable medical

equipment determination performed by nurse practitioner, physician
assistant or clinical nurse specialist B

✽ G0455 Preparation with instillation of fecal microbiota by any method,

including assessment of donor specimen Q1
Coding Clinic: 2013, Q3, P8
✽ G0458 Low dose rate (LDR) prostate brachytherapy services, composite
rate B

✽ G0459 Inpatient telehealth pharmacologic management, including

prescription, use, and review of medication with no more than
minimal medical psychotherapy B

✽ G0460 Autologous platelet rich plasma for non-diabetic chronic

wounds/ulcers, including phlebotomy, centrifugation, and all other
preparatory procedures, administration and dressings, per treatment
T

✽ G0463 Hospital outpatient clinic visit for assessment and management of a

patient J2

✽ G0464 Colorectal cancer screening; stool-based DNA and fecal occult

hemoglobin (e.g., KRAS, NDRG4 and BMP3)
Cross Reference 81528
Laboratory Certification: General immunology, Routine chemistry,
Clinical cytogenetics
✽ G0465 Autologous platelet rich plasma (prp) for diabetic chronic
wounds/ulcers, using an FDA-cleared device (includes
administration, dressings, phlebotomy, centrifugation, and all other
preparatory procedures, per treatment) T

Federally Qualified Health Center Visits

✽ G0466 Federally qualified health center (FQHC) visit, new patient; a
medically-necessary, face-to-face encounter (one-on-one) between a
new patient and a FQHC practitioner during which time one or more
FQHC services are rendered and includes a typical bundle of
Medicare-covered services that would be furnished per diem to a
patient receiving a FQHC visit A

✽ G0467 Federally qualified health center (FQHC) visit, established patient; a

 medically-necessary, face-to-face encounter (one-on-one) between
an established patient and a FQHC practitioner during which time
one or more FQHC services are rendered and includes a typical
bundle of Medicare-covered services that would be furnished per
diem to a patient receiving a FQHC visit A

✽ G0468 Federally qualified health center (FQHC) visit, IPPE or AWV; a

FQHC visit that includes an initial preventive physical examination
(IPPE) or annual wellness visit (AWV) and includes a typical
bundle of Medicare-covered services that would be furnished per
diem to a patient receiving an IPPE or AWV A

✽ G0469 Federally qualified health center (FQHC) visit, mental health, new
patient; a medically-necessary, face-to-face mental health encounter
(one-on-one) between a new patient and a FQHC practitioner during
which time one or more FQHC services are rendered and includes a
typical bundle of Medicare-covered services that would be furnished
per diem to a patient receiving a mental health visit A

✽ G0470 Federally qualified health center (FQHC) visit, mental health,

established patient; a medically-necessary, face-to-face mental
health encounter (one-on-one) between an established patient and a
FQHC practitioner during which time one or more FQHC services
are rendered and includes a typical bundle of Medicare-covered
services that would be furnished per diem to a patient receiving a
mental health visit A

Other Miscellaneous Services

✽ G0471 Collection of venous blood by venipuncture or urine sample by
catheterization from an individual in a skilled nursing facility (SNF)
or by a laboratory on behalf of a home health agency (HHA)
A
❂ G0472 Hepatitis C antibody screening, for individual at high risk and other
covered indication(s) A

Medicare Statute 1861SSA

Laboratory Certification: General immunology
✽ G0473 Face-to-face behavioral counseling for obesity, group (2-10), 30
minutes S

✽ G0475 HIV antigen/antibody, combination assay, screening A

Laboratory Certification: Virology, General immunology

✽ G0476 Infectious agent detection by nucleic acid (DNA or RNA); human
papillomavirus (HPV), high-risk types (e.g., 16, 18, 31, 33, 35, 39,
 45, 51, 52, 56, 58, 59, 68) for cervical cancer screening, must be
performed in addition to pap test A

Laboratory Certification: Virology

Drug Tests
✽ G0480 Drug test(s), definitive, utilizing drug identification methods able to
identify individual drugs and distinguish between structural isomers
(but not necessarily stereoisomers), including, but not limited to
GC/MS (any type, single or tandem) and LC/MS (any type, single
or tandem and excluding immunoassays (e.g., IA, EIA, ELISA,
EMIT, FPIA) and enzymatic methods (e.g., alcohol
dehydrogenase)); qualitative or quantitative, all sources(s), includes
specimen validity testing, per day, 1-7 drug class(es), including
metabolite(s) if performed Q4
Coding Clinic: 2018, Q1, P5
✽ G0481 Drug test(s), definitive, utilizing drug identification methods able to
identify individual drugs and distinguish between structural isomers
(but not necessarily stereoisomers), including, but not limited to
GC/MS (any type, single or tandem) and LC/MS (any type, single
or tandem and excluding immunoassays (e.g., IA, EIA, ELISA,
EMIT, FPIA) and enzymatic methods (e.g., alcohol
dehydrogenase)); qualitative or quantitative, all sources(s), includes
specimen validity testing, per day, 8-14 drug class(es), including
metabolite(s) if performed Q4
Coding Clinic: 2018, Q1, P5
✽ G0482 Drug test(s), definitive, utilizing drug identification methods able to
identify individual drugs and distinguish between structural isomers
(but not necessarily stereoisomers), including, but not limited to
GC/MS (any type, single or tandem) and LC/MS (any type, single
or tandem and excluding immunoassays (e.g., IA, EIA, ELISA,
EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase);
qualitative or quantitative, all sources(s), includes specimen validity
testing, per day, 15-21 drug class(es), including metabolite(s) if
performed Q4
Coding Clinic: 2018, Q1, P5
✽ G0483 Drug test(s), definitive, utilizing drug identification methods able to
identify individual drugs and distinguish between structural isomers
(but not necessarily stereoisomers), including, but not limited to
GC/MS (any type, single or tandem) and LC/MS (any type, single
or tandem and excluding immunoassays (e.g., IA, EIA, ELISA,
 EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase);
qualitative or quantitative, all sources(s), includes specimen validity
testing, per day, 22 or more drug class(es), including metabolite(s) if
performed Q4
Coding Clinic: 2018, Q1, P5

Home Health Nursing Visit: Area of Shortage

✽ G0490 Face-to-face home health nursing visit by a rural health clinic
(RHC) or federally qualified health center (FQHC) in an area with a
shortage of home health agencies (services limited to RN or LPN
only) A

Dialysis Procedure
✽ G0491 Dialysis procedure at a Medicare certified ESRD facility for acute
kidney injury without ESRD B

✽ G0492 Dialysis procedure with single evaluation by a physician or other

qualified health care professional for acute kidney injury without
ESRD B

Home Health or Hospice: Skilled Services

✽ G0493 Skilled services of a registered nurse (RN) for the observation and
assessment of the patient’s condition, each 15 minutes (the change
in the patient’s condition requires skilled nursing personnel to
identify and evaluate the patient’s need for possible modification of
treatment in the home health or hospice setting) B

✽ G0494 Skilled services of a licensed practical nurse (LPN) for the

observation and assessment of the patient’s condition, each 15
minutes (the change in the patient’s condition requires skilled
nursing personnel to identify and evaluate the patient’s need for
possible modification of treatment in the home health or hospice
setting) B

✽ G0495 Skilled services of a registered nurse (RN), in the training and/or

education of a patient or family member, in the home health or
hospice setting, each 15 minutes B

✽ G0496 Skilled services of a licensed practical nurse (LPN), in the training

and/or education of a patient or family member, in the home health
or hospice setting, each 15 minutes B
Chemotherapy Administration
✽ G0498 Chemotherapy administration, intravenous infusion technique;
initiation of infusion in the office/clinic setting using office/clinic
pump/supplies, with continuation of the infusion in the community
setting (e.g., home, domiciliary, rest home or assisted living) using a
portable pump provided by the office/clinic, includes follow up
office/clinic visit at the conclusion of the infusion S

Hepatitis B Screening
✽ G0499 Hepatitis B screening in non-pregnant, high risk individual includes
hepatitis B surface antigen (HBsAG), antibodies to HBsAG (anti-
HBs) and antibodies to hepatitis B core antigen (anti-hbc), and is
followed by a neutralizing confirmatory test, when performed, only
for an initially reactive HBsAG result A

Laboratory Certification: Virology

Moderate Sedation Services

✽ G0500 Moderate sedation services provided by the same physician or other
qualified health care professional performing a gastrointestinal
endoscopic service that sedation supports, requiring the presence of
an independent trained observer to assist in the monitoring of the
patient’s level of consciousness and physiological status; initial 15
minutes of intra-service time; patient age 5 years or older (additional
time may be reported with 99153, as appropriate) N

Resource-Intensive Service
✽ G0501 Resource-intensive services for patients for whom the use of
specialized mobility-assistive technology (such as adjustable height
chairs or tables, patient lift, and adjustable padded leg supports) is
medically necessary and used during the provision of an
office/outpatient, evaluation and management visit (list separately in
addition to primary service) N

Psychiatric Care Management

✽ G0506 Comprehensive assessment of and care planning for patients
requiring chronic care management services (list separately in
addition to primary monthly care management service) N
Critical Care Telehealth Consultation
✽ G0508 Telehealth consultation, critical care, initial, physicians typically
spend 60 minutes communicating with the patient and providers via
telehealth B

✽ G0509 Telehealth consultation, critical care, subsequent, physicians

typically spend 50 minutes communicating with the patient and
providers via telehealth B

Rural Health Clinic: Management and Care

❂ G0511 Rural health clinic or federally qualified health center (RHC or
FQHC) only, general care management, 20 minutes or more of
clinical staff time for chronic care management services or
behavioral health integration services directed by an RHC or FQHC
practitioner (physician, NP, PA, or CNM), per calendar month A

❂ G0512 Rural health clinic or federally qualified health center (RHC/FQHC)

only, psychiatric collaborative care model (psychiatric CoCM), 60
minutes or more of clinical staff time for psychiatric CoCM services
directed by an RHC or FQHC practitioner (physician, NP, PA, or
CNM) and including services furnished by a behavioral health care
manager and consultation with a psychiatric consultant, per calendar
month A

Prolonged Preventive Services

✽ G0513 Prolonged preventive service(s) (beyond the typical service time of
the primary procedure), in the office or other outpatient setting
requiring direct patient contact beyond the usual service; first 30
minutes (list separately in addition to code for preventive service)
N
✽ G0514 Prolonged preventive service(s) (beyond the typical service time of
the primary procedure), in the office or other outpatient setting
requiring direct patient contact beyond the usual service; each
additional 30 minutes (list separately in addition to code G0513 for
additional 30 minutes of preventive service) N

Non-biodegradable Drug Delivery Implants: Removal and Insertion

✽ G0516 Insertion of non-biodegradable drug delivery implants, 4 or more
(services for subdermal rod implant) Q1

✽ G0517 Removal of non-biodegradable drug delivery implants, 4 or more

 (services for subdermal implants) Q1

✽ G0518 Removal with reinsertion, nonbiodegradable drug delivery implants,

4 or more (services for subdermal implants) Q1

Drug Test
✽ G0659 Drug test(s), definitive, utilizing drug identification methods able to
identify individual drugs and distinguish between structural isomers
(but not necessarily stereoisomers), including but not limited to
GC/MS (any type, single or tandem) and LC/MS (any type, single
or tandem), excluding immunoassays (e.g., IA, EIA, ELISA, EMIT,
FPIA) and enzymatic methods (e.g., alcohol dehydrogenase),
performed without method or drug-specific calibration, without
matrixmatched quality control material, or without use of stable
isotope or other universally recognized internal standard(s) for each
drug, drug metabolite or drug class per specimen; qualitative or
quantitative, all sources, includes specimen validity testing, per day,
any number of drug classes Q4

Quality Care Measures: Cataract Surgery

✽ G0913 Improvement in visual function achieved within 90 days following
cataract surgery M

✽ G0914 Patient care survey was not completed by patient M

✽ G0915 Improvement in visual function not achieved within 90 days

following cataract surgery M

✽ G0916 Satisfaction with care achieved within 90 days following cataract

surgery M

✽ G0917 Patient care survey was not completed by patient M

✽ G0918 Satisfaction with care not achieved within 90 days following

cataract surgery M

Clinical Decision Support Mechanism

✽ G1001 Clinical decision support mechanism eviCore, as defined by the
Medicare Appropriate Use Criteria Program E1

✽ G1002 Clinical decision support mechanism MedCurrent, as defined by the

Medicare Appropriate Use Criteria Program E1

✽ G1003 Clinical decision support mechanism Medicalis, as defined by the

Medicare Appropriate Use Criteria Program E1
✽ G1004 Clinical decision support mechanism National Decision Support
Company, as defined by the Medicare Appropriate Use Criteria
Program E1

✽ G1007 Clinical decision support mechanism AIM Specialty Health, as

defined by the Medicare Appropriate Use Criteria Program E1

✽ G1008 Clinical decision support mechanism Cranberry Peak, as defined by

the Medicare Appropriate Use Criteria Program E1

✽ G1009 Clinical decision support mechanism Sage Health Management

Solutions, as defined by the Medicare Appropriate Use Criteria
Program E1

✽ G1010 Clinical decision support mechanism Stanson, as defined by the

Medicare Appropriate Use Criteria Program E1

✽ G1011 Clinical decision support mechanism, qualified tool not otherwise

specified, as defined by the Medicare Appropriate Use Criteria
Program E1

✽ G1012 Clinical decision support mechanism AgileMD, as defined by the

Medicare appropriate use criteria program E1

✽ G1013 Clinical decision support mechanism EvidenceCare ImagingCare, as

defined by the Medicare appropriate use criteria program E1

✽ G1014 Clinical decision support mechanism InveniQA semantic answers in

medicine, as defined by the Medicare appropriate use criteria
program E1

✽ G1015 Clinical decision support mechanism Reliant Medical Group, as

defined by the Medicare appropriate use criteria program E1

✽ G1016 Clinical decision support mechanism Speed of Care, as defined by

the Medicare appropriate use criteria program E1

✽ G1017 Clinical decision support mechanism HealthHelp, as defined by the

Medicare appropriate use criteria program E1

✽ G1018 Clinical decision support mechanism Infinx, as defined by the

Medicare appropriate use criteria program E1

✽ G1019 Clinical decision support mechanism LogicNets, as defined by the

Medicare appropriate use criteria program E1

✽ G1020 Clinical decision support mechanism Curbside Clinical Augmented

Workflow, as defined by the Medicare appropriate use criteria
program E1

✽ G1021 Clinical decision support mechanism E*HealthLine clinical decision

support mechanism, as defined by the Medicare appropriate use
 criteria program E1

✽ G1022 Clinical decision support mechanism Intermountain clinical decision

support mechanism, as defined by the Medicare appropriate use
criteria program E1

✽ G1023 Clinical decision support mechanism Persivia clinical decision

support, as defined by the Medicare appropriate use criteria program
E1
✽ G1024 Clinical decision support mechanism radrite, as defined by the
medicare appropriate use criteria program E1

✽ G1025 Patient-months where there are more than one medicare capitated
payment (mcp) provider listed for the month M

✽ G1026 The number of adult patient-months in the denominator who were

on maintenance hemodialysis using a catheter continuously for three
months or longer under the care of the same practitioner or group
partner as of the last hemodialysis session of the reporting month M
✽ G1027 The number of adult patient-months in the denominator who were
on maintenance hemodialysis under the care of the same practitioner
or group partner as of the last hemodialysis session of the reporting
month using a catheter continuously for less than three months M

✽ G1028 Take-home supply of nasal naloxone; 2-pack of 8mg per 0.1 ml

nasal spray (provision of the services by a medicare-enrolled opioid
treatment program); list separately in addition to code for primary
procedure A

Therapy, Evaluation and Assessment

✽ G2000 Blinded administration of convulsive therapy procedure, either
electroconvulsive therapy (ECT, current covered gold standard) or
magnetic seizure therapy (MST, non-covered experimental therapy),
performed in an approved IDE-based clinical trial, per treatment
session S

✽ G2010 Remote evaluation of recorded video and/or images submitted by an

established patient (e.g., store and forward), including interpretation
with follow-up with the patient within 24 business hours, not
originating from a related E/M service provided within the previous
7 days nor leading to an E/M service or procedure within the next
24 hours or soonest available appointment M

✽ G2011 Alcohol and/or substance (other than tobacco) misuse structured

assessment (e.g., audit, dast), and brief intervention, 5-14 minutes S
✽ G2012 Brief communication technology-based service, e.g., virtual check-
in, by a physician or other qualified health care professional who
can report evaluation and management services, provided to an
established patient, not originating from a related E/M service
provided within the previous 7 days nor leading to an E/M service
or procedure within the next 24 hours or soonest available
appointment; 5-10 minutes of medical discussion M

✽ G2020 Services for high intensity clinical services associated with the
initial engagement and outreach of beneficiaries assigned to the sip
component of the pcf model (do not bill with chronic care
management codes) A

✽ G2021 Health care practitioners rendering treatment in place (TIP) E1

✽ G2022 A model participant (ambulance supplier/provider), the beneficiary

refuses services covered under the model (transport to an alternate
destination/treatment in place) E1

✽ G2023 Specimen collection for severe acute respiratory syndrome

coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]),
any specimen source B

✽ G2024 Specimen collection for severe acute respiratory syndrome

coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19])
from an individual in a SNF or by a laboratory on behalf of a HHA,
any specimen source B

✽ G2025 Payment for a telehealth distant site service furnished by a rural

health clinic (RHC) or federally qualified health center (FQHC)
only A

✽ G2061 Qualified nonphysician healthcare professional online assessment

and management service, for an established patient, for up to seven
days, cumulative time during the 7 days; 5-10 minutes M

✽ G2062 Qualified nonphysician healthcare professional online assessment

and management service, for an established patient, for up to seven
days, cumulative time during the 7 days; 11-20 minutes M

✽ G2063 Qualified nonphysician qualified healthcare professional assessment

and management service, for an established patient, for up to seven
days, cumulative time during the 7 days; 21 or more minutes M

✽ G2066 Interrogation device evaluation(s), (remote) up to 30 days;

implantable cardiovascular physiologic monitor system, implantable
loop recorder system, or subcutaneous cardiac rhythm monitor
system, remote data acquisition(s), receipt of transmissions and
 technician review, technical support and distribution of results Q1

✽ G2067 Medication assisted treatment, methadone; weekly bundle including

dispensing and/or administration, substance use counseling,
individual and group therapy, and toxicology testing, if performed
(provision of the services by a Medicare-enrolled opioid treatment
program) E1

✽ G2068 Medication assisted treatment, buprenorphine (oral); weekly bundle

including dispensing and/or administration, substance use
counseling, individual and group therapy, and toxicology testing if
performed (provision of the services by a Medicare-enrolled opioid
treatment program) E1

✽ G2069 Medication assisted treatment, buprenorphine (injectable); weekly

bundle including dispensing and/or administration, substance use
counseling, individual and group therapy, and toxicology testing if
performed (provision of the services by a Medicare-enrolled opioid
treatment program) E1

✽ G2070 Medication assisted treatment, buprenorphine (implant insertion);

weekly bundle including dispensing and/or administration,
substance use counseling, individual and group therapy, and
toxicology testing if performed (provision of the services by a
Medicare-enrolled opioid treatment program) E1

✽ G2071 Medication assisted treatment, buprenorphine (implant removal);

weekly bundle including dispensing and/or administration,
substance use counseling, individual and group therapy, and
toxicology testing if performed (provision of the services by a
Medicare-enrolled opioid treatment program) E1

✽ G2072 Medication assisted treatment, buprenorphine (implant insertion and

removal); weekly bundle including dispensing and/or
administration, substance use counseling, individual and group
therapy, and toxicology testing if performed (provision of the
services by a Medicare-enrolled opioid treatment program) E1

✽ G2073 Medication assisted treatment, naltrexone; weekly bundle including

dispensing and/or administration, substance use counseling,
individual and group therapy, and toxicology testing if performed
(provision of the services by a Medicare-enrolled opioid treatment
program) E1

✽ G2074 Medication assisted treatment, weekly bundle not including the

drug, including substance use counseling, individual and group
therapy, and toxicology testing if performed (provision of the
 services by a Medicare-enrolled opioid treatment program) E1

✽ G2075 Medication assisted treatment, medication not otherwise specified;

weekly bundle including dispensing and/or administration,
substance use counseling, individual and group therapy, and
toxicology testing, if performed (provision of the services by a
Medicare-enrolled opioid treatment program) E1

✽ G2076 Intake activities, including initial medical examination that is a

complete, fully documented physical evaluation and initial
assessment by a program physician or a primary care physician, or
an authorized healthcare professional under the supervision of a
program physician qualified personnel that includes preparation of a
treatment plan that includes the patient’s short-term goals and the
tasks the patient must perform to complete the short-term goals; the
patient’s requirements for education, vocational rehabilitation, and
employment; and the medical, psycho-social, economic, legal, or
other supportive services that a patient needs, conducted by
qualified personnel (provision of the services by a Medicare-
enrolled opioid treatment program); list separately in addition to
code for primary procedure E1

✽ G2077 Periodic assessment; assessing periodically by qualified personnel

to determine the most appropriate combination of services and
treatment (provision of the services by a Medicare-enrolled opioid
treatment program); list separately in addition to code for primary
procedure E1

✽ G2078 Take-home supply of methadone; up to 7 additional day supply

(provision of the services by a Medicare-enrolled opioid treatment
program); list separately in addition to code for primary procedure
E1
✽ G2079 Take-home supply of buprenorphine (oral); up to 7 additional day
supply (provision of the services by a Medicare-enrolled opioid
treatment program); list separately in addition to code for primary
procedure E1

✽ G2080 Each additional 30 minutes of counseling in a week of medication

assisted treatment, (provision of the services by a Medicare-enrolled
opioid treatment program); list separately in addition to code for
primary procedure E1

✽ G2081 Patients age 66 and older in institutional special needs plans (SNP)
or residing in long-term care with a POS code 32, 33, 34, 54 or 56
for more than 90 consecutive days during the measurement period
M
✽ G2082 Office or other outpatient visit for the evaluation and management
of an established patient that requires the supervision of a physician
or other qualified health care professional and provision of up to 56
mg of esketamine nasal self-administration, includes 2 hours post-
administration observation S

✽ G2083 Office or other outpatient visit for the evaluation and management
of an established patient that requires the supervision of a physician
or other qualified health care professional and provision of greater
than 56 mg esketamine nasal self-administration, includes 2 hours
post-administration observation S

✽ G2086 Office-based treatment for opioid use disorder, including

development of the treatment plan, care coordination, individual
therapy and group therapy and counseling; at least 70 minutes in the
first calendar month S

✽ G2087 Office-based treatment for opioid use disorder, including care

coordination, individual therapy and group therapy and counseling;
at least 60 minutes in a subsequent calendar month S

✽ G2088 Office-based treatment for opioid use disorder, including care

coordination, individual therapy and group therapy and counseling;
each additional 30 minutes beyond the first 120 minutes (list
separately in addition to code for primary procedure) N

✽ G2090 Patients 66 years of age and older with at least one claim/encounter
for frailty during the measurement period and a dispensed
medication for dementia during the measurement period or the year
prior to the measurement period N1 M

✽ G2091 Patients 66 years of age and older with at least one claim/encounter
for frailty during the measurement period and either one acute
inpatient encounter with a diagnosis of advanced illness or two
outpatient, observation, ED or nonacute inpatient encounters on
different dates of service with an advanced illness diagnosis during
the measurement period or the year prior to the measurement period
N1 M
✽ G2092 Angiotensin converting enzyme (ACE) inhibitor or angiotensin
receptor blocker (ARB) or angiotensin receptor-neprilysin inhibitor
(AMI) therapy prescribed or currently being taken N1 M

✽ G2093 Documentation of medical reason(s) for not prescribing ACE

inhibitor or ARB or AMI therapy (e.g., hypotensive patients who
are at immediate risk of cardiogenic shock, hospitalized patients
who have experienced marked azotemia, allergy, intolerance, other
medical reasons) N1 M
✽ G2094 Documentation of patient reason(s) for not prescribing ACE
inhibitor or ARB or AMI therapy (e.g., patient declined, other
patient reasons) N1 M

G2095 Documentation of system reason(s) for not prescribing ACE ✖

inhibitor or ARB or AMI therapy (e.g., other system reasons)
✽ G2096 Angiotensin converting enzyme (ACE) inhibitor or angiotensin
receptor blocker (ARB) or angiotensin receptorneprilysin inhibitor
(AMI) therapy was not prescribed, reason not given N1 M

✽ G2097 Episodes where the patient had a competing diagnosis on or within

three days after the episode date (e.g., intestinal infection, pertussis,
bacterial infection, Lyme disease, otitis media, acute sinusitis, acute
pharyngitis, acute tonsillitis, chronic sinusitis, infection of the
pharynx/larynx/tonsils/adenoids, prostatitis, cellulitis, mastoiditis, or
bone infections, acute lymphadenitis, impetigo, skin staph
infections, pneumonia/gonococcal infections, venereal disease
(syphilis, chlamydia, inflammatory diseases [female reproductive
organs]), infections of the kidney, cystitis or UTI N1 M

✽ G2098 Patients 66 years of age and older with at least one claim/encounter
for frailty during the measurement period and a dispensed
medication for dementia during the measurement period or the year
prior to the measurement period N1 M

✽ G2099 Patients 66 years of age and older with at least one claim/encounter
for frailty during the measurement period and either one acute
inpatient encounter with a diagnosis of advanced illness or two
outpatient, observation, ED or nonacute inpatient encounters on
different dates of service with an advanced illness diagnosis during
the measurement period or the year prior to the measurement period
N1 M
✽ G2100 Patients 66 years of age and older with at least one claim/encounter
for frailty during the measurement period and a dispensed
medication for dementia during the measurement period or the year
prior to the measurement period N1 M

✽ G2101 Patients 66 years of age and older with at least one claim/encounter
for frailty during the measurement period and either one acute
inpatient encounter with a diagnosis of advanced illness or two
outpatient, observation, ED or nonacute inpatient encounters on
different dates of service with an advanced illness diagnosis during
the measurement period or the year prior to the measurement period
N1 M
✽ G2105 Patients age 66 or older in institutional special needs plans (SNP) or
 residing in long-term care with POS code 32, 33, 34, 54 or 56 for
more than 90 days consecutive during the measurement period
N1 M
✽ G2106 Patients 66 years of age and older with at least one claim/encounter
for frailty during the measurement period and a dispensed
medication for dementia during the measurement period or the year
prior to the measurement period N1 M

✽ G2107 Patients 66 years of age and older with at least one claim/encounter
for frailty during the measurement period and either one acute
inpatient encounter with a diagnosis of advanced illness or two
outpatient, observation, ED or nonacute inpatient encounters on
different dates of service with an advanced illness diagnosis during
the measurement period or the year prior to the measurement period
N1 M
✽ G2108 Patients age 66 or older in institutional special needs plans (SNP) or
residing in long-term care with POS code 32, 33, 34, 54 or 56 for
more than 90 days consecutive during the measurement period
N1 M
✽ G2109 Patients 66 years of age and older with at least one claim/encounter
for frailty during the measurement period and a dispensed
medication for dementia during the measurement period or the year
prior to the measurement period N1 M

✽ G2110 Patients 66 years of age and older with at least one claim/encounter
for frailty during the measurement period and either one acute
inpatient encounter with a diagnosis of advanced illness or two
outpatient, observation, ED or nonacute inpatient encounters on
different dates of service with an advanced illness diagnosis during
the measurement period or the year prior to the measurement period
N1 M
✽ G2112 Patient receiving <=5 mg daily prednisone (or equivalent), or RA
activity is worsening, or glucocorticoid use is for less than 6 months
N1 M
✽ G2113 Patient receiving >5 mg daily prednisone (or equivalent) for longer
than 6 months, and improvement or no change in disease activity
N1 M
✽ G2115 Patients 66-80 years of age with at least one claim/encounter for
frailty during the measurement period and a dispensed medication
for dementia during the measurement period or the year prior to the
measurement period N1 M

✽ G2116 Patients 66-80 years of age with at least one claim/encounter for
frailty during the measurement period and either one acute inpatient
encounter with a diagnosis of advanced illness or two outpatient,
 observation, ED or nonacute inpatient encounters on different dates
of service with an advanced illness diagnosis during the
measurement period or the year prior to the measurement period
N1 M
✽ G2118 Patients 81 years of age and older with at least one claim/encounter
for frailty during the measurement period N1 M

✽ G2121 Depression, anxiety, apathy, and psychosis assessed N1 M

✽ G2122 Depression, anxiety, apathy, and psychosis not assessed N1 M

✽ G2125 Patients 81 years of age and older with at least one claim/encounter
for frailty during the six months prior to the measurement period
through December 31 of the measurement period N1 M

✽ G2126 Patients 66-80 years of age with at least one claim/encounter for
frailty during the measurement period and either one acute inpatient
encounter with a diagnosis of advanced illness or two outpatient,
observation, ED or nonacute inpatient encounters on different dates
of service with an advanced illness diagnosis during the
measurement period or the year prior to the measurement period
N1 M
✽ G2127 Patients 66-80 years of age with at least one claim/encounter for
frailty during the measurement period and a dispensed dementia
medication N1 M

✽ G2128 Documentation of medical reason(s) for not on a daily aspirin or

other antiplatelet (e.g. history of gastrointestinal bleed, intra-cranial
bleed, blood disorders, idiopathic thrombocytopenic purpura [ITP],
gastric bypass or documentation of active anticoagulant use during
the measurement period) N1 M

✽ G2129 Procedure-related BP’s not taken during an outpatient visit.

Examples include same day surgery, ambulatory service center, G.I.
lab, dialysis, infusion center, chemotherapy N1 M

✽ G2136 Back pain measured by the Visual Analog Scale (VAS) or numeric
pain scale at three months (6 - 20 weeks) postoperatively was less
than or equal to 3.0 or back pain measured by the Visual Analog
Scale (VAS) or numeric pain scale within three months
preoperatively and at three months (6 - 20 weeks) postoperatively
demonstrated an improvement of 5.0 points or greater N1 M

✽ G2137 Back pain measured by the Visual Analog Scale (VAS) or numeric
pain scale at three months (6 - 20 weeks) postoperatively was
greater than 3.0 and back pain measured by the Visual Analog Scale
(VAS) or numeric pain scale within three months preoperatively and
 at three months (6 - 20 weeks) postoperatively demonstrated a
change of less than an improvement of 5.0 points N1 M

✽ G2138 Back pain as measured by the Visual Analog Scale (VAS) or

numeric pain scale at one year (9 to 15 months) postoperatively was
less than or equal to 3.0 or back pain measured by the Visual Analog
Scale (VAS) or numeric pain scale within three months
preoperatively and at one year (9 to 15 months) postoperatively
demonstrated a change of 5.0 points or greater N1 M

✽ G2139 Back pain measured by the Visual Analog Scale (VAS) or numeric
pain scale pain at one year (9 to 15 months) postoperatively was
greater than 3.0 and back pain measured by the Visual Analog Scale
(VAS) or numeric pain scale within three months preoperatively and
at one year (9 to 15 months) postoperatively demonstrated a change
of less than 5.0 N1 M

✽ G2140 Leg pain measured by the Visual Analog Scale (VAS) or numeric
pain scale at three months (6 - 20 weeks) postoperatively was less
than or equal to 3.0 or leg pain measured by the Visual Analog Scale
(VAS) or numeric pain scale within three months preoperatively and
at three months (6 - 20 weeks) postoperatively demonstrated an
improvement of 5.0 points or greater N1 M

✽ G2141 Leg pain measured by the Visual Analog Scale (VAS) or numeric
pain scale at three months (6 - 20 weeks) postoperatively was
greater than 3.0 and leg pain measured by the Visual Analog Scale
(VAS) or numeric pain scale within three months preoperatively and
at three months (6 - 20 weeks) postoperatively demonstrated less
than an improvement of 5.0 points N1 M

✽ G2142 Functional status measured by the Oswestry Disability Index (ODI

version 2.1a) at one year (9 to 15 months) postoperatively was less
than or equal to 22 or functional status measured by the ODI version
2.1a within three months preoperatively and at one year (9 to 15
months) postoperatively demonstrated an improvement of 30 points
or greater N1 M

✽ G2143 Functional status measured by the Oswestry Disability Index (ODI

version 2.1a) at one year (9 to 15 months) postoperatively was
greater than 22 and functional status measured by the ODI version
2.1a within three months preoperatively and at one year (9 to 15
months) postoperatively demonstrated an improvement of less than
30 points N1 M

✽ G2144 Functional status measured by the Oswestry Disability Index (ODI

version 2.1a) at three months (6 - 20 weeks) postoperatively was
 less than or equal to 22 or functional status measured by the ODI
version 2.1a within three months preoperatively and at three months
(6 - 20 weeks) postoperatively demonstrated an improvement of 30
points or greater
✽ G2145 Functional status measured by the Oswestry Disability Index (ODI
version 2.1a) at three months (6 - 20 weeks) postoperatively was
greater than 22 and functional status measured by the ODI version
2.1a within three months preoperatively and at three months (6 - 20
weeks) postoperatively demonstrated an improvement of less than
30 points N1 M

✽ G2146 Leg pain as measured by the Visual Analog Scale (VAS) or numeric
pain scale at one year (9 to 15 months) postoperatively was less than
or equal to 3.0 or leg pain measured by the Visual Analog Scale
(VAS) or numeric pain scale within three months preoperatively and
at one year (9 to 15 months) postoperatively demonstrated an
improvement of 5.0 points or greater N1 M

✽ G2147 Leg pain measured by the Visual Analog Scale (VAS) or numeric
pain scale at one year (9 to 15 months) postoperatively was greater
than 3.0 and leg pain measured by the Visual Analog Scale (VAS) or
numeric pain scale within three months preoperatively and at one
year (9 to 15 months) postoperatively demonstrated less than an
improvement of 5.0 points N1 M

✽ G2148 Multimodal pain management was used N1 M

✽ G2149 Documentation of medical reason(s) for not using multimodal pain

management (e.g., allergy to multiple classes of analgesics,
intubated patient, hepatic failure, patient reports no pain during
PACU stay, other medical reason(s)) N1 M

✽ G2150 Multimodal pain management was not used N1 M

✽ G2151 Documentation stating patient has a diagnosis of a degenerative

neurological condition such as ALS, MS, Parkinson’s diagnosed at
any time before or during the episode of care N1 M

✽ G2152 Residual score for the neck impairment successfully calculated and
the score was equal to zero (0) or greater than zero (> 0) N1 M

✽ G2167 Residual score for the neck impairment successfully calculated and
the score was less than zero (< 0) N1 M

✽ G2168 Services performed by a physical therapist assistant in the home

health setting in the delivery of a safe and effective physical therapy
maintenance program, each 15 minutes B
✽ G2169 Services performed by an occupational therapist assistant in the
home health setting in the delivery of a safe and effective
occupational therapy maintenance program, each 15 minutes B

G2170 Percutaneous arteriovenous fistula creation (AVF), direct, any ✖

site, by tissue approximation using thermal resistance energy, and
secondary procedures to redirect blood flow (e.g., transluminal
balloon angioplasty, coil embolization) when performed, and
includes all imaging and radiologic guidance, supervision and
interpretation, when performed
G2171 Percutaneous arteriovenous fistula creation (AVF), direct, any ✖
site, using magnetic-guided arterial and venous catheters and
radiofrequency energy, including flow-directing procedures (e.g.,
vascular coil embolization with radiologic supervision and
interpretation, wen performed) and fistulogram(s), angiography,
enography, and/or ultrasound, with radiologic supervision and
interpretation, when performed
✽ G2172 All inclusive payment for services related to highly coordinated and
integrated opioid use disorder (oud) treatment services furnished for
the demonstration project A

✽ G2173 URI episodes where the patient had a comorbid condition during the
12 months prior to or on the episode date (e.g., tuberculosis,
neutropenia, cystic fibrosis, chronic bronchitis, pulmonary edema,
respiratory failure, rheumatoid lung disease) M

✽ G2174 URI episodes when the patient had an active prescription of

antibiotics in the 30 days prior to the episode date or is still active
the same day of the encounter M

✽ G2175 Episodes where the patient had a comorbid condition during the 12
months prior to or on the episode date (e.g., tuberculosis,
neutropenia, cystic fibrosis, chronic bronchitis, pulmonary edema,
respiratory failure, rheumatoid lung disease) M

✽ G2176 Outpatient, ED, or observation visits that result in an inpatient

admission M

✽ G2177 Acute bronchitis/bronchiolitis episodes when the patient had a new

or refill prescription of antibiotics (table 1) in the 30 days prior to
the episode date
✽ G2178 Clinician documented that patient was not an eligible candidate for
lower extremity neurological exam measure, for example patient
bilateral amputee; patient has condition that would not allow them
to accurately respond to a neurological exam (dementia,
 Alzheimer’s, etc.); patient has previously documented diabetic
peripheral neuropathy with loss of protective sensation M

✽ G2179 Clinician documented that patient had medical reason for not
performing lower extremity neurological exam M

✽ G2180 Clinician documented that patient was not an eligible candidate for
evaluation of footwear as patient is bilateral lower extremity
amputee M

✽ G2181 BMI not documented due to medical reason or patient refusal of

height or weight measurement M

✽ G2182 Patient receiving first-time biologic and/or immune response

modifier therapy M

✽ G2183 Documentation patient unable to communicate and informant not

available M

✽ G2184 Patient does not have a caregiver M

✽ G2185 Documentation caregiver is trained and certified in dementia care

M
✽ G2186 Patient /caregiver dyad has been referred to appropriate resources
and connection to those resources is confirmed M

✽ G2187 Patients with clinical indications for imaging of the head: Head
trauma M

✽ G2188 Patients with clinical indications for imaging of the head: New or
change in headache above 50 years of age M

✽ G2189 Patients with clinical indications for imaging of the head: Abnormal
neurologic exam M

✽ G2190 Patients with clinical indications for imaging of the head: Headache
radiating to the neck M

✽ G2191 Patients with clinical indications for imaging of the head: Positional
headaches M

✽ G2192 Patients with clinical indications for imaging of the head: Temporal
headaches in patients over 55 years of age M

✽ G2193 Patients with clinical indications for imaging of the head: New onset
headache in pre-school children or younger (<6 years of age) M

✽ G2194 Patients with clinical indications for imaging of the head: New onset
headache in pediatric patients with disabilities for which headache is
a concern as inferred from behavior M

✽ G2195 Patients with clinical indications for imaging of the head: Occipital
headache in children M
✽ G2196 Patient identified as an unhealthy alcohol user when screened for
unhealthy alcohol use using a systematic screening method M

✽ G2197 Patient screened for unhealthy alcohol use using a systematic

screening method and not identified as an unhealthy alcohol user M
G2198 Documentation of medical reason(s) for not screening for ✖
unhealthy alcohol use using a systematic screening method (e.g.,
limited life expectancy, other medical reasons)
✽ G2199 Patient not screened for unhealthy alcohol use using a systematic
screening method M

✽ G2200 Patient identified as an unhealthy alcohol user received brief

counseling M

G2201 Patient identified as an unhealthy alcohol user received brief ✖

counseling
✽ G2202 Patient did not receive brief counseling if identified as an unhealthy
alcohol user M

G2203 Documentation of medical reason(s) for not providing brief ✖

counseling if identified as an unhealthy alcohol user (e.g., limited
life expectancy, other medical reasons)
✽ G2204 Patients between 45 and 85 years of age who received a screening
colonoscopy during the performance period M

✽ G2205 Patients with pregnancy during adjuvant treatment course M

✽ G2206 Patient received adjuvant treatment course including both

chemotherapy and her 2-targeted therapy M

✽ G2207 Reason for not administering adjuvant treatment course including

both chemotherapy and her2-targeted therapy (e.g., poor
performance status (ECOG 3-4; Karnofsky < 50), cardiac
contraindications, insufficient renal function, insufficient hepatic
function, other active or secondary cancer diagnoses, other medical
contraindications, patients who died during initial treatment course
or transferred during or after initial treatment course) M

✽ G2208 Patient did not receive adjuvant treatment course including both
chemotherapy and her 2-targeted therapy M

✽ G2209 Patient refused to participate M

✽ G2210 Residual score for the neck impairment not measured because the
patient did not complete the neck fs prom at initial evaluation and/or
near discharge, reason not given M

✽ G2211 Visit complexity inherent to evaluation and management associated

with medical care services that serve as the continuing focal point
 for all needed health care services and/or with medical care services
that are part of ongoing care related to a patient’s single, serious
condition or a complex condition. (Add-on code, list separately in
addition to office/outpatient evaluation and management visit, new
or established) N

✽ G2212 Prolonged office or other outpatient evaluation and management

service(s) beyond the maximum required time of the primary
procedure which has been selected using total time on the date of
the primary service; each additional 15 minutes by the physician or
qualified healthcare professional, with or without direct patient
contact (list separately in addition to CPT codes 99205, 99215,
99483 for office or other outpatient evaluation and management
services) (do not report G2212 on the same date of service as 99358,
99359, 99415, 99416). (Do not report G2212 for any time unit less
than 15 minutes) N

✽ G2213 Initiation of medication for the treatment of opioid use disorder in

the emergency department setting, including assessment, referral to
ongoing care, and arranging access to supportive services (list
separately in addition to code for primary procedure) N

✽ G2214 Initial or subsequent psychiatric collaborative care management,

first 30 minutes in a month of behavioral health care manager
activities, in consultation with a psychiatric consultant, and directed
by the treating physician or other qualified health care professional
S
✽ G2215 Take-home supply of nasal naloxone; 2-pack of 4mg per 0.1 ml
nasal spray (provision of the services by a Medicare-enrolled opioid
treatment program); list separately in addition to code for primary
procedure A

✽ G2216 Take-home supply of injectable naloxone (provision of the services

by a Medicare-enrolled opioid treatment program); list separately in
addition to code for primary procedure A

✽ G2250 Remote assessment of recorded video and/or images submitted by

an established patient (e.g., store and forward), including
interpretation with follow-up with the patient within 24 business
hours, not originating from a related service provided within the
previous 7 days nor leading to a service or procedure within the next
24 hours or soonest available appointment A

✽ G2251 Brief communication technology-based service, e.g., virtual check-

in, by a qualified health care professional who cannot report
Evaluation and Management services, provided to an established
 patient, not originating from a related service provided within the
previous 7 days nor leading to a service or procedure within the next
24 hours or soonest available appointment; 5-10 minutes of clinical
discussion A

✽ G2252 Brief communication technology-based service, e.g., virtual check-

in, by a physician or other qualified health care professional who
can report Evaluation and Management services, provided to an
established patient, not originating from a related e/m service
provided within the previous 7 days nor leading to an e/m service or
procedure within the next 24 hours or soonest available
appointment; 11-20 minutes of medical discussion A

Pain Management
▶ G3002 Chronic pain management and treatment, monthly bundle including,
diagnosis; assessment and monitoring; administration of a validated
pain rating scale or tool; the development, implementation, revision,
and/or maintenance of a person-centered care plan that includes
strengths, goals, clinical needs, and desired outcomes; overall
treatment management; facilitation and coordination of any
necessary behavioral health treatment; medication management;
pain and health literacy counseling; any necessary chronic pain
related crisis care; and ongoing communication and care
coordination between relevant practitioners furnishing care, e.g.
physical therapy and occupational therapy, complementary and
integrative approaches, and community-based care, as appropriate.
Required initial face-to-face visit at least 30 minutes provided by a
physician or other qualified health professional; first 30 minutes
personally provided by physician or other qualified health care
professional, per calendar month. (When using G3002, 30 minutes
must be met or exceeded.) M

▶ G3003 Each additional 15 minutes of chronic pain management and

treatment by a physician or other qualified health care professional,
per calendar month. (List separately in addition to code for G3002.
When using G3003, 15 minutes must be met or exceeded.) M

Specialty Set
✽ G4000 Dermatology mips specialty set M

✽ G4001 Diagnostic radiology mips specialty set M

✽ G4002 Electrophysiology cardiac specialist mips specialty set M

✽ G4003 Emergency medicine mips specialty set M

✽ G4004 Endocrinology mips specialty set M

✽ G4005 Family medicine mips specialty set M

✽ G4006 Gastro-enterology mips specialty set M

✽ G4007 General surgery mips specialty set M

✽ G4008 Geriatrics mips specialty set M

✽ G4009 Hospitalists mips specialty set M

✽ G4010 Infectious disease mips specialty set M

✽ G4011 Internal medicine mips specialty set M

✽ G4012 Interventional radiology mips specialty set M

✽ G4013 Mental/behavioral and psychiatry mips specialty set M

✽ G4014 Nephrology mips specialty set M

✽ G4015 Neurology mips specialty set M

✽ G4016 Neurosurgical mips specialty set M

✽ G4017 Nutrition/dietician mips specialty set M

✽ G4018 Obstetrics/gynecology mips specialty set M

✽ G4019 Oncology/hematology mips specialty set M

✽ G4020 Ophthalmology/optometry mips specialty set M

✽ G4021 Orthopedic surgery mips specialty set M

✽ G4022 Otolaryngology mips specialty set M

✽ G4023 Pathology mips specialty set M

✽ G4024 Pediatrics mips specialty set M

✽ G4025 Physical medicine mips specialty set M

✽ G4026 Physical therapy/occupational therapy mips specialty set M

✽ G4027 Plastic surgery mips specialty set M

✽ G4028 Podiatry mips specialty set M

✽ G4029 Preventive medicine mips specialty set M

✽ G4030 Pulmonology mips specialty set M

✽ G4031 Radiation oncology mips specialty set M

✽ G4032 Rheumatology mips specialty set M

✽ G4033 Skilled nursing facility mips specialty set M

✽ G4034 Speech language pathology mips specialty set M

 ✽ G4035 Thoracic surgery mips specialty set M

✽ G4036 Urgent care mips specialty set M

✽ G4037 Urology mips specialty set M

✽ G4038 Vascular surgery mips specialty set M

Guidance
❂ G6001 Ultrasonic guidance for placement of radiation therapy fields
B
✽ G6002 Stereoscopic x-ray guidance for localization of target volume for the
delivery of radiation therapy B

Radiation Treatment
✽ G6003 Radiation treatment delivery, single treatment area, single port or
parallel opposed ports, simple blocks or no blocks: up to 5 mev
B

✽ G6004 Radiation treatment delivery, single treatment area, single port or

parallel opposed ports, simple blocks or no blocks: 6-10 mev
B
✽ G6005 Radiation treatment delivery, single treatment area, single port or
parallel opposed ports, simple blocks or no blocks: 11-19 mev
B
✽ G6006 Radiation treatment delivery, single treatment area, single port or
parallel opposed ports, simple blocks or no blocks: 20 mev or
greater B

✽ G6007 Radiation treatment delivery, 2 separate treatment areas, 3 or more

ports on a single treatment area, use of multiple blocks: up to 5 mev
B

✽ G6008 Radiation treatment delivery, 2 separate treatment areas, 3 or more

ports on a single treatment area, use of multiple blocks: 6-10 mev
B

✽ G6009 Radiation treatment delivery, 2 separate treatment areas, 3 or more

ports on a single treatment area, use of multiple blocks: 11-19 mev
B

✽ G6010 Radiation treatment delivery, 2 separate treatment areas, 3 or more

ports on a single treatment area, use of multiple blocks: 20 mev or
greater B

✽ G6011 Radiation treatment delivery, 3 or more separate treatment areas,

 custom blocking, tangential ports, wedges, rotational beam,
compensators, electron beam; up to 5 mev B

✽ G6012 Radiation treatment delivery, 3 or more separate treatment areas,

custom blocking, tangential ports, wedges, rotational beam,
compensators, electron beam; 6-10 mev B

✽ G6013 Radiation treatment delivery, 3 or more separate treatment areas,

custom blocking, tangential ports, wedges, rotational beam,
compensators, electron beam; 11-19 mev B

✽ G6014 Radiation treatment delivery, 3 or more separate treatment areas,

custom blocking, tangential ports, wedges, rotational beam,
compensators, electron beam; 20 mev or greater B

✽ G6015 Intensity modulated treatment delivery, single or multiple

fields/arcs, via narrow spatially and temporally modulated beams,
binary, dynamic MLC, per treatment session B

✽ G6016 Compensator-based beam modulation treatment delivery of inverse

planned treatment using 3 or more high resolution (milled or cast)
compensator, convergent beam modulated fields, per treatment
session B

✽ G6017 Intra-fraction localization and tracking of target or patient motion

during delivery of radiation therapy (e.g., 3D positional tracking,
gating, 3D surface tracking), each fraction of treatment B
Quality Measures
✽ G8395 Left ventricular ejection fraction (LVEF) >=40% or documentation
as normal or mildly depressed left ventricular systolic function M

✽ G8396 Left ventricular ejection fraction (LVEF) not performed or

documented M

✽ G8397 Dilated macular or fundus exam performed, including

documentation of the presence or absence of macular edema and
level of severity of retinopathy M

✽ G8399 Patient with documented results of a central dual-energy x-ray

absorptiometry (DXA) ever being performed M

✽ G8400 Patient with central dual-energy x-ray absorptiometry (DXA) results

not documented M

✽ G8404 Lower extremity neurological exam performed and documented

M
✽ G8405 Lower extremity neurological exam not performed M

✽ G8410 Footwear evaluation performed and documented M

✽ G8415 Footwear evaluation was not performed M

✽ G8416 Clinician documented that patient was not an eligible candidate for
footwear evaluation measure M

✽ G8417 BMI is documented above normal parameters and a follow-up plan

is documented M

✽ G8418 BMI is documented below normal parameters and a follow-up plan

is documented M

✽ G8419 BMI is documented outside normal parameters, no follow-up plan

documented, no reason given M

✽ G8420 BMI is documented within normal parameters and no follow-up

plan is required M

✽ G8421 BMI not documented and no reason is given M

✽ G8427 Eligible clinician attests to documenting in the medical record they

obtained, updated, or reviewed the patient’s current medications
M
✽ G8428 Current list of medications not documented as obtained, updated, or
reviewed by the eligible clinician, reason not given M

✽ G8430 Documentation of a medical reason(s) for not documenting,

updating, or reviewing the patient’s current medications list (e.g.,
patient is in an urgent or emergent medical situation) M

Screening for depression is documented as being positive and a

✽ G8431 follow-up plan is documented M

✽ G8432 Depression screening not documented, reason not given M

✽ G8433 Screening for depression not completed, documented patient or

medical reason M

✽ G8450 Beta-blocker therapy prescribed M

✽ G8451 Beta-blocker therapy for LVEF <40% not prescribed for reasons
documented by the clinician (e.g., low blood pressure, fluid
overload, asthma, patients recently treated with an intravenous
positive inotropic agent, allergy, intolerance, other medical reasons,
patient declined, other patient reasons M

✽ G8452 Beta-blocker therapy not prescribed M

✽ G8465 High or very high risk of recurrence of prostate cancer ♂ M

✽ G8473 Angiotensin converting enzyme (ACE) inhibitor or angiotensin

receptor blocker (ARB) therapy prescribed M

✽ G8474 Angiotensin converting enzyme (ACE) inhibitor or angiotensin

receptor blocker (ARB) therapy not prescribed for reasons
documented by the clinician (e.g., allergy, intolerance, pregnancy,
renal failure due to ACE inhibitor, diseases of the aortic or mitral
valve, other medical reasons) or (e.g., patient declined, other patient
reasons) or (e.g., lack of drug availability, other reasons attributable
to the health care system) M

✽ G8475 Angiotensin converting enzyme (ACE) inhibitor or angiotensin

receptor blocker (ARB) therapy not prescribed, reason not given
M
✽ G8476 Most recent blood pressure has a systolic measurement of <140
mmHg and a diastolic measurement of <90 mmHg M

✽ G8477 Most recent blood pressure has a systolic measurement of >=140

mmHg and/or a diastolic measurement of >=90 mmHg M

✽ G8478 Blood pressure measurement not performed or documented, reason

not given M

✽ G8482 Influenza immunization administered or previously received M

✽ G8483 Influenza immunization was not administered for reasons

documented by clinician (e.g., patient allergy or other medical
reasons, patient declined or other patient reasons, vaccine not
available or other system reasons) M

✽ G8484 Influenza immunization was not administered, reason not given

M
✽ G8506 Patient receiving angiotensin converting enzyme (ACE) inhibitor or
 angiotensin receptor blocker (ARB) therapy M

✽ G8510 Screening for depression is documented as negative, a follow-up

plan is not required M

✽ G8511 Screening for depression documented as positive, follow up plan not

documented, reason not given M

✽ G8535 Elder maltreatment screen not documented; documentation that

patient is not eligible for the elder maltreatment screen at the time of
the encounter M

✽ G8536 No documentation of an elder maltreatment screen, reason not given

M

✽ G8539 Functional outcome assessment documented as positive using a

standardized tool and a care plan based on identified deficiencies is
documented within two days of the functional outcome assessment
M
✽ G8540 Functional outcome assessment not documented as being
performed, documentation the patient is not eligible for a functional
outcome assessment using a standardized tool at the time of the
encounter M

✽ G8541 Functional outcome assessment using a standardized tool not

documented, reason not given M

✽ G8542 Functional outcome assessment using a standardized tool is

documented; no functional deficiencies identified, care plan not
required M

✽ G8543 Documentation of a positive functional outcome assessment using a

standardized tool; care plan not documented within two days of
assessment, reason not given M

✽ G8559 Patient referred to a physician (preferably a physician with training

in disorders of the ear) for an otologic evaluation M

✽ G8560 Patient has a history of active drainage from the ear within the
previous 90 days M

✽ G8561 Patient is not eligible for the referral for otologic evaluation for
patients with a history of active drainage measure M

✽ G8562 Patient does not have a history of active drainage from the ear
within the previous 90 days M

✽ G8563 Patient not referred to a physician (preferably a physician with

training in disorders of the ear) for an otologic evaluation, reason
not given M

✽ G8564 Patient was referred to a physician (preferably a physician with

 training in disorders of the ear) for an otologic evaluation, reason
not specified M

✽ G8565 Verification and documentation of sudden or rapidly progressive

hearing loss M

✽ G8566 Patient is not eligible for the “referral for otologic evaluation for
sudden or rapidly progressive hearing loss” measure M

✽ G8567 Patient does not have verification and documentation of sudden or

rapidly progressive hearing loss M

✽ G8568 Patient was not referred to a physician (preferably a physician with

training in disorders of the ear) for an otologic evaluation, reason
not given M

✽ G8569 Prolonged postoperative intubation (>24 hrs) required M

✽ G8570 Prolonged postoperative intubation (>24 hrs) not required M

✽ G8575 Developed postoperative renal failure or required dialysis M

✽ G8576 No postoperative renal failure/dialysis not required M

✽ G8577 Re-exploration required due to mediastinal bleeding with or without

tamponade, graft occlusion, valve disfunction, or other cardiac
reason M

✽ G8578 Re-exploration not required due to mediastinal bleeding with or

without tamponade, graft occlusion, valve dysfunction, or other
cardiac reason M

✽ G8598 Aspirin or another antiplatelet therapy used M

✽ G8599 Aspirin or another antiplatelet therapy not used, reason not given
M
✽ G8600 IV thrombolytic therapy initiated within 4.5 hours (<= 270 minutes)
of time last known well M

✽ G8601 IV thrombolytic therapy not initiated within 4.5 hours (= 270

minutes) of time last known well for reasons documented by
clinician (e.g. patient enrolled in clinical trial for stroke, patient
admitted for elective carotid intervention, patient received
tenecteplase [tnk]) M

✽ G8602 IV thrombolytic therapy not initiated within 4.5 hours (= 270

minutes) of time last known well, reason not given M

✽ G8633 Pharmacologic therapy (other than minerals/vitamins) for

osteoporosis prescribed M

✽ G8635 Pharmacologic therapy for osteoporosis was not prescribed, reason

not given M

Residual score for the knee impairment successfully calculated and

✽ G8647 the score was equal to zero (0) or greater than zero (>0) M

✽ G8648 Residual score for the knee impairment successfully calculated and
the score was less than zero (<0) M

✽ G8650 Residual scores for the knee impairment not measured because the
patient did not complete the LEPT prom at initial evaluation and/or
near discharge, reason not given M

✽ G8651 Residual score for the hip impairment successfully calculated and
the score was equal to zero (0) or greater than zero (>0) M

✽ G8652 Residual score for the hip impairment successfully calculated and
the score was less than zero (<0) M

✽ G8654 Residual scores for the hip impairment not measured because the
patient did not complete LEPT prom at initial evaluation and/or
follow up status survey near discharge, reason not given M

✽ G8655 Residual score for the foot or ankle impairment successfully

calculated and the score was equal to zero (0) or greater than zero
(>0) M

✽ G8656 Residual score for the foot or ankle impairment successfully

calculated and the score was less than zero (<0) M

✽ G8658 Residual scores for the lower leg, foot or ankle impairment not
measured because the patient did not complete LEPT prom at initial
evaluation and/or follow up status survey near discharge, reason not
given M

✽ G8659 Residual score for the low back impairment successfully calculated
and the score was equal to zero (0) or greater than zero (>0) M

✽ G8660 Residual score for the low back impairment successfully calculated
and the score was less than zero (<0) M

✽ G8661 Risk-adjusted functional status change residual scores for the low
back impairment not measured because the patient did not complete
FOTO’S status survey near discharge, patient not appropriate M

✽ G8662 Residual scores for the low back impairment not measured because
the patient did not complete the low back FS prom at initial
evaluation and/or near discharge, reason not given M

✽ G8663 Residual score for the shoulder impairment successfully calculated

and the score was equal to zero (0) or greater than zero (>0) M

✽ G8664 Residual score for the shoulder impairment successfully calculated

and the score was less than zero (<0) M

✽ G8666 Residual scores for the shoulder impairment not measured because
the patient did not complete the shoulder FS prom at initial
 evaluation and/or near discharge, reason not given M

✽ G8667 Residual score for the elbow, wrist or hand impairment successfully
calculated and the score was equal to zero (0) or greater than zero
(>0) M

✽ G8668 Residual score for the elbow, wrist or hand impairment successfully
calculated and the score was less than zero (<0) M

✽ G8670 Residual scores for the elbow, wrist or hand impairment not
measured because the patient did not complete the the
elbow/wrist/hand FS prom at initial evaluation near discharge,
reason not given M

✽ G8694 Left ventriucular ejection fraction (LVEF) <=40% or documentation

of moderate or severe LVSD M

✽ G8708 Patient not prescribed antibiotic M

✽ G8709 URI episodes when the patient had competing diagnoses on or three
days after the episode date (e.g., intestinal infection, pertussis,
bacterial infection, Lyme disease, otitis media, acute sinusitis, acute
pharyngitis, acute tonsillitis, chronic sinusitis, infection of the
pharynx/larynx/tonsils/adenoids, prostatitis, cellulitis, mastoiditis, or
bone infections, acute lymphadenitis, impetigo, skin staph
infections, pneumonia/gonococcal infections, venereal disease
[syphilis, chlamydia, inflammatory diseases (female reproductive
organs)], infections of the kidney, cystitis or UTI, and acne) M

✽ G8710 Patient prescribed antibiotic M

✽ G8711 Prescribed antibiotic on or within 3 days after the episode date M

✽ G8712 Antibiotic not prescribed or dispensed M

✽ G8721 PT category (primary tumor), PN category (regional lymph nodes),

and histologic grade were documented in pathology report M

✽ G8722 Documentation of medical reason(s) for not including the PT

category, the PN category or the histologic grade in the pathology
report (e.g., re-excision without residual tumor; noncarcinomasanal
canal) M

✽ G8723 Specimen site is other than anatomic location of primary tumor

M
✽ G8724 PT category, PN category and histologic grade were not documented
in the pathology report, reason not given M

✽ G8733 Elder maltreatment screen documented as positive and a follow-up

plan is documented M

✽ G8734 Elder maltreatment screen documented as negative, follow-up is not

 required M

✽ G8735 Elder maltreatment screen documented as positive, follow-up plan

not documented, reason not given M

✽ G8749 Absence of signs of melanoma (tenderness, jaundice, localized

neurologic signs such as weakness, or any other sign suggesting
systemic spread) or absence of symptoms of melanoma (cough,
dyspnea, pain, paresthesia, or any other symptom suggesting the
possibility of systemic spread of melanoma) M

✽ G8752 Most recent systolic blood pressure <140 mmhg M

✽ G8753 Most recent systolic blood pressure >=140 mmhg M

✽ G8754 Most recent diastolic blood pressure <90 mmhg M

✽ G8755 Most recent diastolic blood pressure >=90 mmhg M

✽ G8756 No documentation of blood pressure measurement, reason not given

M
✽ G8783 Normal blood pressure reading documented, follow-up not required
M
✽ G8785 Blood pressure reading not documented, reason not given M

✽ G8797 Specimen site other than anatomic location of esophagus M

✽ G8798 Specimen site other than anatomic location of prostate M

✽ G8806 Performance of trans-abdominal or trans-vaginal ultrasound and

pregnancy location documented M

✽ G8807 Trans-abdominal or trans-vaginal ultrasound not performed for

reasons documented by clinician (e.g., patient has visited the ED
multiple times within 72 hours, patient has a documented
intrauterine pregnancy [IUP]) M

✽ G8808 Trans-abdominal or trans-vaginal ultrasound not performed, reason

not given M

✽ G8815 Documented reason in the medical records for why the statin
therapy was not prescribed (i.e., lower extremity bypass was for a
patient with nonartherosclerotic disease) M

✽ G8816 Statin medication prescribed at discharge M

✽ G8817 Statin therapy not prescribed at discharge, reason not given M

✽ G8818 Patient discharge to home no later than post-operative day #7 M

✽ G8825 Patient not discharged to home by post-operative day #7 M

✽ G8826 Patient discharged to home no later than post-operative day #2

following EVAR M

Patient not discharged to home by post-operative day #2 following

✽ G8833 EVAR M

✽ G8834 Patient discharged to home no later than post-operative day #2

following CEA M

✽ G8838 Patient not discharged to home by post-operative day #2 following

CEA M

✽ G8839 Sleep apnea symptoms assessed, including presence or absence of

snoring and daytime sleepiness M

✽ G8840 Documentation of reason(s) for not documenting an assessment of

sleep symptoms (e.g., patient didn’t have initial daytime sleepiness,
patient visited between initial testing and initiation of therapy) M

✽ G8841 Sleep apnea symptoms not assessed, reason not given M

✽ G8842 Apnea Hypopnea Index (AHI) or Respiratory Disturbance Index

(RDI), or Respiratory Event Index (REI) documented or measured
within 2 months of initial evaluation for suspected obstructive sleep
apnea M

✽ G8843 Documentation of reason(s) for not measuring an Apnea Hypopnea

Index (AHI) or a Respiratory Disturbance Index (RDI), or a
Respiratory Event Index (REI) within 2 months of initial evaluation
for suspected obstructive sleep apnea (e.g., medical, neurological, or
psychiatric disease that prohibits successful completion of a sleep
study, patients for whom a sleep study would present a bigger risk
than benefit or would pose an undue burden, dementia, patients who
decline AHI/RDI/REI measurement, patients who had a financial
reason for not completing testing, test was ordered but not
completed, patients decline because their insurance [payer] does not
cover the expense) M

✽ G8844 Apnea Hypopnea Index (AHI) or Respiratory Disturbance Index

(RDI), or Respiratory Event Index (REI) not documented or
measured within 2 months of initial evaluation for suspected
obstructive sleep apnea, reason not given M

✽ G8845 Positive airway pressure therapy prescribed M

✽ G8846 Moderate or severe obstructive sleep apnea (Apnea Hypopnea Index

(AHI) or Respiratory Disturbance Index (RDI) of 15 or greater)
M
✽ G8849 Documentation of reason(s) for not prescribing positive airway
pressure therapy (e.g., patient unable to tolerate, alternative
therapies use, patient declined, financial, insurance coverage) M

✽ G8850 Positive airway pressure therapy not prescribed, reason not given
M
✽ G8851 Objective measurement of adherence to positive airway pressure
therapy, documented M

✽ G8852 Positive airway pressure therapy was prescribed M

✽ G8854 Documentation of reason(s) for not objectively measuring

adherence to positive airway pressure therapy (e.g., patient didn’t
bring data from continuous positive airway pressure [CPAP],
therapy not yet initiated, not available on machine) M

✽ G8855 Objective measurement of adherence to positive airway pressure

therapy not performed, reason not given M

✽ G8856 Referral to a physician for an otologic evaluation performed M

✽ G8857 Patient is not eligible for the referral for otologic evaluation measure
(e.g., patients who are already under the care of a physician for
acute or chronic dizziness) M

✽ G8858 Referral to a physician for an otologic evaluation not performed,

reason not given M

✽ G8863 Patients not assessed for risk of bone loss, reason not given M

✽ G8864 Pneumococcal vaccine administered or previously received M

✽ G8865 Documentation of medical reason(s) for not administering or

previously receiving pneumococcal vaccine (e.g., patient allergic
reaction, potential adverse drug reaction) M

✽ G8866 Documentation of patient reason(s) for not administering or

previously receiving pneumococcal vaccine (e.g., patient refusal)
M
✽ G8867 Pneumococcal vaccine not administered or previously received,
reason not given M

✽ G8869 Patient has documented immunity to hepatitis B and initiating anti-

TNF therapy M

✽ G8875 Clinician diagnosed breast cancer preoperatively by a minimally

invasive biopsy method M

✽ G8876 Documentation of reason(s) for not performing minimally invasive

biopsy to diagnose breast cancer preoperatively (e.g., lesion too
close to skin, implant, chest wall, etc., lesion could not be
adequately visualized for needle biopsy, patient condition prevents
needle biopsy [weight, breast thickness, etc.], duct excision without
imaging abnormality, prophylactic mastectomy, reduction
mammoplasty, excisional biopsy performed by another physician)
M
✽ G8877 Clinician did not attempt to achieve the diagnosis of breast cancer
preoperatively by a minimally invasive biopsy method, reason not
 given M

✽ G8878 Sentinel lymph node biopsy procedure performed M

✽ G8880 Documentation of reason(s) sentinel lymph node biopsy not

performed (e.g., reasons could include but not limited to: non-
invasive cancer, incidental discovery of breast cancer on
prophylactic mastectomy, incidental discovery of breast cancer on
reduction mammoplasty, pre-operative biopsy proven lymph node
(LN) metastases, inflammatory carcinoma, stage 3 locally advanced
cancer, recurrent invasive breast cancer, clinically node positive
after neoadjuvant systemic therapy, patient refusal after informed
consent; patient with significant age, comorbidities, or limited life
expectancy and favorable tumor; adjuvant systemic therapy unlikely
to change) M

✽ G8881 Stage of breast cancer is greater than T1N0M0 or T2N0M0 M

✽ G8882 Sentinel lymph node biopsy procedure not performed, reason not
given M

✽ G8883 Biopsy results reviewed, communicated, tracked and documented

M
✽ G8884 Clinician documented reason that patient’s biopsy results were not
reviewed M

✽ G8885 Biopsy results not reviewed, communicated, tracked or documented

M
✽ G8907 Patient documented not to have experienced any of the following
events: a burn prior to discharge; a fall within the facility; wrong
site/side/patient/procedure/implant event; or a hospital transfer or
hospital admission upon discharge from the facility M

✽ G8908 Patient documented to have received a burn prior to discharge M

✽ G8909 Patient documented not to have received a burn prior to discharge

M
✽ G8910 Patient documented to have experienced a fall within ASC M

✽ G8911 Patient documented not to have experienced a fall within

ambulatory surgical center M

✽ G8912 Patient documented to have experienced a wrong site, wrong side,

wrong patient, wrong procedure or wrong implant event M

✽ G8913 Patient documented not to have experienced a wrong site, wrong

side, wrong patient, wrong procedure or wrong implant event M

✽ G8914 Patient documented to have experienced a hospital transfer or

hospital admission upon discharge from ASC M

✽ G8915 Patient documented not to have experienced a hospital transfer or

 hospital admission upon discharge from ASC M

✽ G8916 Patient with preoperative order for IV antibiotic surgical site

infection (SSI) prophylaxis, antibiotic initiated on time M

✽ G8917 Patient with preoperative order for IV antibiotic surgical site

infection (SSI) prophylaxis, antibiotic not initiated on time M

✽ G8918 Patient without preoperative order for IV antibiotic surgical site

infection(SSI) prophylaxis M

✽ G8923 Left ventricular ejection fraction (LVEF) <=40% or documentation

of moderately or severely depressed left ventricular systolic function
M
✽ G8924 Spirometry test results demonstrate FEV1/FVC <70%, FEV 1 <60%
predicted and patient has COPD symptoms (e.g., dyspnea,
cough/sputum, wheezing) M

✽ G8934 Left ventricular ejection fraction (LVEF) <=40% or documentation

of moderately or severely depressed left ventricular systolic function
M
✽ G8935 Clinician prescribed angiotensin converting enzyme (ACE) inhibitor
or angiotensin receptor blocker (ARB) therapy M

✽ G8937 Clinician did not prescribe angiotensin converting enzyme (ACE)

inhibitor or angiotensin receptor blocker (ARB) therapy, reason not
given M

✽ G8939 Pain assessment documented as positive, follow-up plan not

documented, documentation the patient is not eligible at the time of
the encounter at the time of the encounter M

✽ G8941 Elder maltreatment screen documented as positive, follow-up plan

not documented, documentation the patient is not eligible for
follow-up plan at the time of the encounter M

✽ G8942 Functional outcomes assessment using a standardized tool is

documented within the previous 30 days and care plan, based on
identified deficiencies is documented within two days of the
functional outcome assessment M

✽ G8944 AJCC melanoma cancer stage 0 through IIC melanoma M

✽ G8946 Minimally invasive biopsy method attempted but not diagnostic of

breast cancer (e.g., high risk lesion of breast such as atypical ductal
hyperplasia, lobular neoplasia, atypical lobular hyperplasia, lobular
carcinoma in situ, atypical columnar hyperplasia, flat epithelial
atypia, radial scar, complex sclerosing lesion, papillary lesion, or
any lesion with spindle cells) M

✽ G8950 Elevated or hypertensive blood pressure reading documented, and

 the indicated follow-up documented M

✽ G8952 Elevated or hypertensive blood pressure reading documented,

indicated follow-up not documented, reason not given M

✽ G8955 Most recent assessment of adequacy of volume management

documented M

✽ G8956 Patient receiving maintenance hemodialysis in an outpatient dialysis

facility M

✽ G8958 Assessment of adequacy of volume management not documented,

reason not given M

✽ G8961 Cardiac stress imaging test primarily performed on low-risk surgery

patient for preoperative evaluation within 30 days preceding this
surgery M

✽ G8962 Cardiac stress imaging test performed on patient for any reason
including those who did not have low risk surgery or test that was
performed more than 30 days preceding low risk surgery M

✽ G8963 Cardiac stress imaging performed primarily for monitoring of

asymptomatic patient who had PCI within 2 years M

✽ G8964 Cardiac stress imaging test performed primarily for any other reason
than monitoring of asymptomatic patient who had PCI within 2
years (e.g., symptomatic patient, patient greater than 2 years since
PCI, initial evaluation, etc.) M

✽ G8965 Cardiac stress imaging test primarily performed on low CHD risk
patient for initial detection and risk assessment M

✽ G8966 Cardiac stress imaging test performed on symptomatic or higher

than low CHD risk patient or for any reason other than initial
detection and risk assessment M

✽ G8967 FDA-approved oral anticoagulant is prescribed M

✽ G8968 Documentation of medical reason(s) for not prescribing an FDA-

approved anticoagulant (e.g., present or planned atrial appendage
occlusion or ligation M

✽ G8969 Documentation of patient reason(s) for not prescribing an oral

anticoagulant that is FDA approved for the prevention of
thromboembolism (e.g., patient choice of having atrial appendage
device placed) M

✽ G8970 No risk factors or one moderate risk factor for thromboembolism

M

Coordinated Care
 ❂ G9001 Coordinated care fee, initial rate B

❂ G9002 Coordinated care fee, maintenance rate B

❂ G9003 Coordinated care fee, risk adjusted high, initial B

❂ G9004 Coordinated care fee, risk adjusted low, initial B

❂ G9005 Coordinated care fee, risk adjusted maintenance B

❂ G9006 Coordinated care fee, home monitoring B

❂ G9007 Coordinated care fee, scheduled team conference B

❂ G9008 Coordinated care fee, physician coordinated care oversight services

B
❂ G9009 Coordinated care fee, risk adjusted maintenance, level 3 B

❂ G9010 Coordinated care fee, risk adjusted maintenance, level 4 B

❂ G9011 Coordinated care fee, risk adjusted maintenance, level 5 B

❂ G9012 Other specified case management services not elsewhere classified

B

Demonstration Project
G9013 ESRD demo basic bundle Level I E1

G9014 ESRD demo expanded bundle including venous access and related
services E1

G9016 Smoking cessation counseling, individual, in the absence of or in

addition to any other evaluation and management service, per
session (6-10 minutes) [demo project code only] E1

G9050 Oncology; primary focus of visit; work-up, evaluation, or staging at

the time of cancer diagnosis or recurrence (for use in a Medicare-
approved demonstration project) E1

G9051 Oncology; primary focus of visit; treatment decision-making after

disease is staged or restaged, discussion of treatment options,
supervising/coordinating active cancer directed therapy or managing
consequences of cancer directed therapy (for use in a Medicare-
approved demonstration project) E1

G9052 Oncology; primary focus of visit; surveillance for disease recurrence

for patient who has completed definitive cancer-directed therapy
and currently lacks evidence of recurrent disease; cancer directed
therapy might be considered in the future (for use in a Medicare-
approved demonstration project) E1

G9053 Oncology; primary focus of visit; expectant management of patient

with evidence of cancer for whom no cancer directed therapy is
 being administered or arranged at present; cancer directed therapy
might be considered in the future (for use in a Medicare-approved
demonstration project) E1

G9054 Oncology; primary focus of visit; supervising, coordinating or

managing care of patient with terminal cancer or for whom other
medical illness prevents further cancer treatment; includes symptom
management, end-of-life care planning, management of palliative
therapies (for use in a Medicare-approved demonstration project)
E1
G9055 Oncology; primary focus of visit; other, unspecified service not
otherwise listed (for use in a Medicare-approved demonstration
project) E1

G9056 Oncology; practice guidelines; management adheres to guidelines

(for use in a Medicare-approved demonstration project) E1

G9057 Oncology; practice guidelines; management differs from guidelines

as a result of patient enrollment in an institutional review board
approved clinical trial (for use in a Medicareapproved
demonstration project) E1

G9058 Oncology; practice guidelines; management differs from guidelines

because the treating physician disagrees with guideline
recommendations (for use in a Medicare-approved demonstration
project) E1

G9059 Oncology; practice guidelines; management differs from guidelines

because the patient, after being offered treatment consistent with
guidelines, has opted for alternative treatment or management,
including no treatment (for use in a Medicare-approved
demonstration project) E1

G9060 Oncology; practice guidelines; management differs from guidelines

for reason(s) associated with patient comorbid illness or
performance status not factored into guidelines (for use in a
Medicare-approved demonstration project) E1

G9061 Oncology; practice guidelines; patient’s condition not addressed by

available guidelines (for use in a Medicareapproved demonstration
project) E1

G9062 Oncology; practice guidelines; management differs from guidelines

for other reason(s) not listed (for use in a Medicare-approved
demonstration project) E1

✽ G9063 Oncology; disease status; limited to non-small cell lung cancer;

extent of disease initially established as stage I (prior to neo-
adjuvant therapy, if any) with no evidence of disease progression,
 recurrence, or metastases (for use in a Medicare-approved
demonstration project) M

✽ G9064 Oncology; disease status; limited to non-small cell lung cancer;

extent of disease initially established as stage II (prior to neo-
adjuvant therapy, if any) with no evidence of disease progression,
recurrence, or metastases (for use in a Medicare-approved
demonstration project) M

✽ G9065 Oncology; disease status; limited to non-small cell lung cancer;

extent of disease initially established as stage IIIA (prior to neo-
adjuvant therapy, if any) with no evidence of disease progression,
recurrence, or metastases (for use in a Medicare-approved
demonstration project) M

✽ G9066 Oncology; disease status; limited to non-small cell lung cancer;

stage IIIB-IV at diagnosis, metastatic, locally recurrent, or
progressive (for use in a Medicare-approved demonstration project)
M
✽ G9067 Oncology; disease status; limited to non-small cell lung cancer;
extent of disease unknown, staging in progress, or not listed (for use
in a Medicareapproved demonstration project) M

✽ G9068 Oncology; disease status; limited to small cell and combined small
cell/nonsmall cell; extent of disease initially established as limited
with no evidence of disease progression, recurrence, or metastases
(for use in a Medicareapproved demonstration project) M

✽ G9069 Oncology; disease status; small cell lung cancer, limited to small
cell and combined small cell/non-small cell; extensive stage at
diagnosis, metastatic, locally recurrent, or progressive (for use in a
Medicare-approved demonstration project) M

✽ G9070 Oncology; disease status; small cell lung cancer, limited to small
cell and combined small cell/non-small cell; extent of disease
unknown, staging in progress, or not listed (for use in a Medicare-
approved demonstration project) M

✽ G9071 Oncology; disease status; invasive female breast cancer (does not
include ductal carcinoma in situ); adenocarcinoma as predominant
cell type; stage I or stage IIA-IIB; or T3, N1, M0; and ER and/or PR
positive; with no evidence of disease progression, recurrence, or
metastases (for use in a Medicare-approved demonstration project)
♀ M

✽ G9072 Oncology; disease status; invasive female breast cancer (does not
include ductal carcinoma in situ); adenocarcinoma as predominant
cell type; stage I, or stage IIA-IIB; or T3, N1, M0; and ER and PR
 negative; with no evidence of disease progression, recurrence, or
metastases (for use in a Medicare-approved demonstration project)
♀ M

✽ G9073 Oncology; disease status; invasive female breast cancer (does not
include ductal carcinoma in situ); adenocarcinoma as predominant
cell type; stage IIIA-IIIB; and not T3, N1, M0; and ER and/or PR
positive; with no evidence of disease progression, recurrence, or
metastases (for use in a Medicare-approved demonstration project)
♀ M

✽ G9074 Oncology; disease status; invasive female breast cancer (does not
include ductal carcinoma in situ); adenocarcinoma as predominant
cell type; stage IIIA-IIIB; and not T3, N1, M0; and ER and PR
negative; with no evidence of disease progression, recurrence, or
metastases (for use in a Medicare-approved demonstration project)
♀ M

✽ G9075 Oncology; disease status; invasive female breast cancer (does not
include ductal carcinoma in situ); adenocarcinoma as predominant
cell type; M1 at diagnosis, metastatic, locally recurrent, or
progressive (for use in a Medicare-approved demonstration project)
♀ M

✽ G9077 Oncology; disease status; prostate cancer, limited to

adenocarcinoma as predominant cell type; T1-T2c and Gleason 2-7
and PSA < or equal to 20 at diagnosis with no evidence of disease
progression, recurrence, or metastases (for use in a Medicare-
approved demonstration project) ♂ M

✽ G9078 Oncology; disease status; prostate cancer, limited to

adenocarcinoma as predominant cell type; T2 or T3a Gleason 8-10
or PSA >20 at diagnosis with no evidence of disease progression,
recurrence, or metastases (for use in a Medicare-approved
demonstration project) ♂ M

✽ G9079 Oncology; disease status; prostate cancer, limited to

adenocarcinoma as predominant cell type; T3b-T4, any N; any T,
N1 at diagnosis with no evidence of disease progression, recurrence,
or metastases (for use in a Medicareapproved demonstration project)
♂ M

✽ G9080 Oncology; disease status; prostate cancer, limited to

adenocarcinoma; after initial treatment with rising PSA or failure of
PSA decline (for use in a Medicare-approved demonstration project)
♂ M
✽ G9083 Oncology; disease status; prostate cancer, limited to
adenocarcinoma; extent of disease unknown, staging in progress, or
not listed (for use in a Medicare-approved demonstration project)
♂ M

✽ G9084 Oncology; disease status; colon cancer, limited to invasive cancer,

adenocarcinoma as predominant cell type; extent of disease initially
established as T1-3, N0, M0 with no evidence of disease
progression, recurrence, or metastases (for use in a Medicare-
approved demonstration project) M

✽ G9085 Oncology; disease status; colon cancer, limited to invasive cancer,

adenocarcinoma as predominant cell type; extent of disease initially
established as T4, N0, M0 with no evidence of disease progression,
recurrence, or metastases (for use in a Medicare-approved
demonstration project) M

✽ G9086 Oncology; disease status; colon cancer, limited to invasive cancer,

adenocarcinoma as predominant cell type; extent of disease initially
established as T1-4, N1-2, M0 with no evidence of disease
progression, recurrence, or metastases (for use in a Medicare-
approved demonstration project) M

✽ G9087 Oncology; disease status; colon cancer, limited to invasive cancer,

adenocarcinoma as predominant cell type; M1 at diagnosis,
metastatic, locally recurrent, or progressive with current clinical,
radiologic, or biochemical evidence of disease (for use in a
Medicare-approved demonstration project) M

✽ G9088 Oncology; disease status; colon cancer, limited to invasive cancer,

adenocarcinoma as predominant cell type; M1 at diagnosis,
metastatic, locally recurrent, or progressive without current clinical,
radiologic, or biochemical evidence of disease (for use in a
Medicare-approved demonstration project) M

✽ G9089 Oncology; disease status; colon cancer, limited to invasive cancer,

adenocarcinoma as predominant cell type; extent of disease
unknown, staging in progress, or not listed (for use in a Medicare-
approved demonstration project) M

✽ G9090 Oncology; disease status; rectal cancer, limited to invasive cancer,

adenocarcinoma as predominant cell type; extent of disease initially
established as T1-2, N0, M0 (prior to neo-adjuvant therapy, if any)
with no evidence of disease progression, recurrence, or metastases
(for use in a Medicare-approved demonstration project) M

✽ G9091 Oncology; disease status; rectal cancer, limited to invasive cancer,

 adenocarcinoma as predominant cell type; extent of disease initially
established as T3, N0, M0 (prior to neoadjuvant therapy, if any)
with no evidence of disease progression, recurrence, or metastases
(for use in a Medicare-approved demonstration project) M

✽ G9092 Oncology; disease status; rectal cancer, limited to invasive cancer,

adenocarcinoma as predominant cell type; extent of disease initially
established as T1-3, N1-2, M0 (prior to neo-adjuvant therapy, if
any) with no evidence of disease progression, recurrence or
metastases (for use in a Medicare-approved demonstration project)
M
✽ G9093 Oncology; disease status; rectal cancer, limited to invasive cancer,
adenocarcinoma as predominant cell type; extent of disease initially
established as T4, any N, M0 (prior to neo-adjuvant therapy, if any)
with no evidence of disease progression, recurrence, or metastases
(for use in a Medicare-approved demonstration project) M

✽ G9094 Oncology; disease status; rectal cancer, limited to invasive cancer,

adenocarcinoma as predominant cell type; M1 at diagnosis,
metastatic, locally recurrent, or progressive (for use in a Medicare-
approved demonstration project) M

✽ G9095 Oncology; disease status; rectal cancer, limited to invasive cancer,

adenocarcinoma as predominant cell type; extent of disease
unknown, staging in progress, or not listed (for use in a Medicare-
approved demonstration project) M

✽ G9096 Oncology; disease status; esophageal cancer, limited to

adenocarcinoma or squamous cell carcinoma as predominant cell
type; extent of disease initially established as T1-T3, N0-N1 or NX
(prior to neo-adjuvant therapy, if any) with no evidence of disease
progression, recurrence, or metastases (for use in a Medicare-
approved demonstration project) M

✽ G9097 Oncology; disease status; esophageal cancer, limited to

adenocarcinoma or squamous cell carcinoma as predominant cell
type; extent of disease initially established as T4, any N, M0 (prior
to neo-adjuvant therapy, if any) with no evidence of disease
progression, recurrence, or metastases (for use in a Medicare-
approved demonstration project) M

✽ G9098 Oncology; disease status; esophageal cancer, limited to

adenocarcinoma or squamous cell carcinoma as predominant cell
type; M1 at diagnosis, meta-static, locally recurrent, or progressive
(for use in a Medicareapproved demonstration project) M

✽ G9099 Oncology; disease status; esophageal cancer, limited to

 adenocarcinoma or squamous cell carcinoma as predominant cell
type; extent of disease unknown, staging in progress, or not listed
(for use in a Medicare-approved demonstration project) M

✽ G9100 Oncology; disease status; gastric cancer, limited to adenocarcinoma

as predominant cell type; post R0 resection (with or without
neoadjuvant therapy) with no evidence of disease recurrence,
progression, or metastases (for use in a Medicare-approved
demonstration project) M

✽ G9101 Oncology; disease status; gastric cancer, limited to adenocarcinoma

as predominant cell type; post R1 or R2 resection (with or without
neoadjuvant therapy) with no evidence of disease progression, or
metastases (for use in a Medicare-approved demonstration project)
M
✽ G9102 Oncology; disease status; gastric cancer, limited to adenocarcinoma
as predominant cell type; clinical or pathologic M0, unresectable
with no evidence of disease progression, or metastases (for use in a
Medicareapproved demonstration project) M

✽ G9103 Oncology; disease status; gastric cancer, limited to adenocarcinoma

as predominant cell type; clinical or pathologic M1 at diagnosis,
metastatic, locally recurrent, or progressive (for use in a Medicare-
approved demonstration project) M

✽ G9104 Oncology; disease status; gastric cancer, limited to adenocarcinoma

as predominant cell type; extent of disease unknown, staging in
progress, or not listed (for use in a Medicare-approved
demonstration project) M

✽ G9105 Oncology; disease status; pancreatic cancer, limited to

adenocarcinoma as predominant cell type; post R0 resection without
evidence of disease progression, recurrence, or metastases (for use
in a Medicare-approved demonstration project) M

✽ G9106 Oncology; disease status; pancreatic cancer, limited to

adenocarcinoma; post R1 or R2 resection with no evidence of
disease progression or metastases (for use in a Medicare-approved
demonstration project) M

✽ G9107 Oncology; disease status; pancreatic cancer, limited to

adenocarcinoma; unresectable at diagnosis, M1 at diagnosis,
metastatic, locally recurrent, or progressive (for use in a
Medicareapproved demonstration project) M

✽ G9108 Oncology; disease status; pancreatic cancer, limited to

adenocarcinoma; extent of disease unknown, staging in progress, or
not listed (for use in a Medicare-approved demonstration project)
 M
✽ G9109 Oncology; disease status; head and neck cancer, limited to cancers
of oral cavity, pharynx and larynx with squamous cell as
predominant cell type; extent of disease initially established as T1-
T2 and N0, M0 (prior to neo-adjuvant therapy, if any) with no
evidence of disease progression, recurrence, or metastases (for use
in a Medicare-approved demonstration project) M

✽ G9110 Oncology; disease status; head and neck cancer, limited to cancers
of oral cavity, pharynx, and larynx with squamous cell as
predominant cell type; extent of disease initially established as T3-4
and/or N1-3, M0 (prior to neo-adjuvant therapy, if any) with no
evidence of disease progression, recurrence, or metastases (for use
in a Medicare-approved demonstration project) M

✽ G9111 Oncology; disease status; head and neck cancer, limited to cancers
of oral cavity, pharynx and larynx with squamous cell as
predominant cell type; M1 at diagnosis, metastatic, locally
recurrent, or progressive (for use in a Medicare-approved
demonstration project) M

✽ G9112 Oncology; disease status; head and neck cancer, limited to cancers
of oral cavity, pharynx and larynx with squamous cell as
predominant cell type; extent of disease unknown, staging in
progress, or not listed (for use in a Medicare-approved
demonstration project) M

✽ G9113 Oncology; disease status; ovarian cancer, limited to epithelial

cancer; pathologic stage IA-B (grade 1) without evidence of disease
progression, recurrence, or metastases (for use in a Medicare-
approved demonstration project) ♀ M

✽ G9114 Oncology; disease status; ovarian cancer, limited to epithelial

cancer; pathologic stage IA-B (grade 2-3); or stage IC (all grades);
or stage II; without evidence of disease progression, recurrence, or
metastases (for use in a Medicare-approved demonstration project)
♀ M

✽ G9115 Oncology; disease status; ovarian cancer, limited to epithelial

cancer; pathologic stage III-IV; without evidence of progression,
recurrence, or metastases (for use in a Medicareapproved
demonstration project) ♀ M

✽ G9116 Oncology; disease status; ovarian cancer, limited to epithelial

cancer; evidence of disease progression, or recurrence and/or
platinum resistance (for use in a Medicare-approved demonstration
project) ♀ M
✽ G9117 Oncology; disease status; ovarian cancer, limited to epithelial
cancer; extent of disease unknown, staging in progress, or not listed
(for use in a Medicare-approved demonstration project) ♀ M

✽ G9123 Oncology; disease status; chronic myelogenous leukemia, limited to

Philadelphia chromosome positive and/or BCR-ABL positive;
chronic phase not in hematologic, cytogenetic, or molecular
remission (for use in a Medicare-approved demonstration project)
M
✽ G9124 Oncology; disease status; chronic myelogenous leukemia, limited to
Philadelphia chromosome positive and/or BCR-ABL positive;
accelerated phase not in hematologic cytogenetic, or molecular
remission (for use in a Medicare-approved demonstration project)
M
✽ G9125 Oncology; disease status; chronic myelogenous leukemia, limited to
Philadelphia chromosome positive and/or BCR-ABL positive; blast
phase not in hematologic, cytogenetic, or molecular remission (for
use in a Medicareapproved demonstration project) M

✽ G9126 Oncology; disease status; chronic myelogenous leukemia, limited to

Philadelphia chromosome positive and/or BCR-ABL positive; in
hematologic, cytogenetic, or molecular remission (for use in a
Medicare-approved demonstration project) M

✽ G9128 Oncology: disease status; limited to multiple myeloma, systemic

disease; smouldering, stage I (for use in a Medicare-approved
demonstration project) M

✽ G9129 Oncology; disease status; limited to multiple myeloma, systemic

disease; stage II or higher (for use in a Medicare-approved
demonstration project) M

✽ G9130 Oncology; disease status; limited to multiple myeloma, systemic

disease; extent of disease unknown, staging in progress, or not listed
(for use in a Medicare-approved demonstration project) M

✽ G9131 Oncology; disease status; invasive female breast cancer (does not
include ductal carcinoma in situ); adenocarcinoma as predominant
cell type; extent of disease unknown, staging in progress, or not
listed (for use in a Medicare-approved demonstration project) ♀
M
✽ G9132 Oncology; disease status; prostate cancer, limited to
adenocarcinoma; hormone-refractory/androgen-independent (e.g.,
rising PSA on antiandrogen therapy or post-orchiectomy); clinical
metastases (for use in a Medicare-approved demonstration project)
♂ M
 ✽ G9133 Oncology; disease status; prostate cancer, limited to
adenocarcinoma; hormone-responsive; clinical metastases or M1 at
diagnosis (for use in a Medicare-approved demonstration project)
♂ M

✽ G9134 Oncology; disease status; non-Hodgkin’s lymphoma, any cellular

classification; stage I, II at diagnosis, not relapsed, not refractory
(for use in a Medicareapproved demonstration project) M

✽ G9135 Oncology; disease status; non-Hodgkin’s lymphoma, any cellular

classification; stage III, IV, not relapsed, not refractory (for use in a
Medicareapproved demonstration project) M

✽ G9136 Oncology; disease status; non-Hodgkin’s lymphoma, transformed

from original cellular diagnosis to a second cellular classification
(for use in a Medicare-approved demonstration project) M

✽ G9137 Oncology; disease status; non-Hodgkin’s lymphoma, any cellular

classification; relapsed/refractory (for use in a Medicare-approved
demonstration project) M

✽ G9138 Oncology; disease status; non-Hodgkin’s lymphoma, any cellular

classification; diagnostic evaluation, stage not determined,
evaluation of possible relapse or non-response to therapy, or not
listed (for use in a Medicareapproved demonstration project) M

✽ G9139 Oncology; disease status; chronic myelogenous leukemia, limited to

Philadelphia chromosome positive and/or BCR-ABL positive;
extent of disease unknown, staging in progress, not listed (for use in
a Medicare-approved demonstration project) M

✽ G9140 Frontier extended stay clinic demonstration; for a patient stay in a

clinic approved for the CMS demonstration project; the following
measures should be present: the stay must be equal to or greater than
4 hours; weather or other conditions must prevent transfer or the
case falls into a category of monitoring and observation cases that
are permitted by the rules of the demonstration; there is a maximum
frontier extended stay clinic (FESC) visit of 48 hours, except in the
case when weather or other conditions prevent transfer; payment is
made on each period up to 4 hours, after the first 4 hours A

Warfarin Responsiveness Testing

✽ G9143 Warfarin responsiveness testing by genetic technique using any
method, any number of specimen(s) N

This would be a once-in-a-lifetime test unless there is a reason to

believe that the patient’s personal genetic characteristics would
 change over time. (https://www.cms.gov/Regulations-and-
Guidance/Guidance/Transmittals/Downloads/R111NCD.pdf)
Laboratory Certification: General immunology, Hematology
Coding Clinic: 2010, Q2, P10

Outpatient IV Insulin Treatment

G9147 Outpatient intravenous insulin treatment (OIVIT) either pulsatile or
continuous, by any means, guided by the results of measurements
for: respiratory quotient; and/or urine urea nitrogen (UUN); and/or
arterial, venous or capillary glucose; and/or potassium concentration
E1
On December 23, 2009, CMS issued a national non-coverage
decision on the use of OIVIT. CR 6775.
Not covered on Physician Fee Schedule
Coding Clinic: 2010, Q2, P10

Quality Assurance
✽ G9148 National Committee for Quality Assurance - level 1 medical home
M
✽ G9149 National Committee for Quality Assurance - level 2 medical home
M
✽ G9150 National Committee for Quality Assurance - level 3 medical home
M
✽ G9151 MAPCP demonstration - state provided services M

✽ G9152 MAPCP demonstration - community health teams M

✽ G9153 MAPCP demonstration - physician incentive pool M

Wheelchair Evaluation
✽ G9156 Evaluation for wheelchair requiring face to face visit with physician
M

Cardiac Monitoring
✽ G9157 Transesophageal doppler measurement of cardiac output (including
probe placement, image acquisition, and interpretation per course of
treatment) for monitoring purposes B

Bundled Payment Care Improvement

✽ G9187 Bundled payments for care improvement initiative home visit for
 patient assessment performed by a qualified health care professional
for individuals not considered homebound including, but not limited
to, assessment of safety, falls, clinical status, fluid status, medication
reconciliation/management, patient compliance with orders/plan of
care, performance of activities of daily living, appropriateness of
care setting; (for use only in the Medicare-approved bundled
payments for care improvement initiative); may not be billed for a
30-day period covered by a transitional care management code
E1

Quality Measures: Miscellaneous

✽ G9188 Beta-blocker therapy not prescribed, reason not given M

✽ G9189 Beta-blocker therapy prescribed or currently being taken M

✽ G9190 Documentation of medical reason(s) for not prescribing beta-

blocker therapy (e.g., allergy, intolerance, other medical reasons)
M
✽ G9191 Documentation of patient reason(s) for not prescribing beta-blocker
therapy (e.g., patient declined, other patient reasons) M

✽ G9192 Documentation of system reason(s) for not prescribing beta-blocker

therapy (e.g., other reasons attributable to the health care system)
M
G9196 Documentation of medical reason(s) for not ordering a first or ✖
second generation cephalosporin for antimicrobial prophylaxis (e.g.,
patients enrolled in clinical trials, patients with documented
infection prior to surgical procedure of interest, patients who were
receiving antibiotics more than 24 hours prior to surgery [except
colon surgery patients taking oral prophylactic antibiotics], patients
who were receiving antibiotics within 24 hours prior to arrival
[except colon surgery patients taking oral prophylactic antibiotics],
other medical reason(s))

G9197 Documentation of order for first or second generation ✖

cephalosporin for antimicrobial prophylaxis

G9198 Order for first or second generation cephalosporin for ✖

antimicrobial prophylaxis was not documented, reason not given

✽ G9212 DSM-IV-TM criteria for major depressive disorder documented at

the initial evaluation M

✽ G9213 DSM-IV-TR criteria for major depressive disorder not documented

 at the initial evaluation, reason not otherwise specified M

✽ G9223 Pneumocystis jiroveci pneumonia prophylaxis prescribed within 3

months of low CD4+ cell count below 500 cells/mm3 or a CD4
percentage below 15% M

✽ G9225 Foot exam was not performed, reason not given M

✽ G9226 Foot examination performed (includes examination through visual

inspection, sensory exam with 10-g monofilament plus testing any
one of the following: vibration using 128-hz tuning fork, pinprick
sensation, ankle reflexes, or vibration perception threshold, and
pulse exam; report when all of the 3 components are completed)
M
✽ G9227 Functional outcome assessment documented, care plan not
documented, documentation the patient is not eligible for a care plan
at the time of the encounter M

✽ G9228 Chlamydia, gonorrhea and syphilis screening results documented

(report when results are present for all of the 3 screenings) M

✽ G9229 Chlamydia, gonorrhea, and syphilis screening results not

documented (patient refusal is the only allowed exception) M

✽ G9230 Chlamydia, gonorrhea, and syphilis not screened, reason not given
M
✽ G9231 Documentation of end stage renal disease (ESRD), dialysis, renal
transplant before or during the measurement period or pregnancy
during the measurement period M

✽ G9242 Documentation of viral load equal to or greater than 200 copies/ml

or viral load not performed M

✽ G9243 Documentation of viral load less than 200 copies/ml M

✽ G9246 Patient did not have at least one medical visit in each 6 month
period of the 24 month measurement period, with a minimum of 60
days between medical visits M

✽ G9247 Patient had at least one medical visit in each 6 month period of the
24 month measurement period, with a minimum of 60 days between
medical visits M

G9250 Documentation of patient pain brought to a comfortable level

✖
within 48 hours from initial assessment

G9251 Documentation of patient with pain not brought to a ✖

comfortable level within 48 hours from initial assessment

✽ G9254 Documentation of patient discharged to home later than post-

operative day 2 following CAS M
✽ G9255 Documentation of patient discharged to home no later than post
operative day 2 following CAS M

✽ G9273 Blood pressure has a systolic value of <140 and a diastolic value of
<90 M

✽ G9274 Blood pressure has a systolic value of = 140 and a diastolic value of
= 90 or systolic value <140 and diastolic value = 90 or systolic
value = 140 and diastolic value <90 M

✽ G9275 Documentation that patient is a current non-tobacco user M

✽ G9276 Documentation that patient is a current tobacco user M

✽ G9277 Documentation that the patient is on daily aspirin or anti-platelet or

has documentation of a valid contraindication or exception to
aspirin/anti-platelet; contraindications/exceptions include anti-
coagulant use, allergy to aspirin or anti-platelets, history of
gastrointestinal bleed and bleeding disorder; additionally, the
following exceptions documented by the physician as a reason for
not taking daily aspirin or anti-platelet are acceptable (use of non-
steroidal anti-inflammatory agents, documented risk for drug
interaction, uncontrolled hypertension defined as >180 systolic or
>110 diastolic or gastroesophageal reflux) M

✽ G9278 Documentation that the patient is not on daily aspirin or anti-platelet

regimen M

✽ G9279 Pneumococcal screening performed and documentation of

vaccination received prior to discharge M

✽ G9280 Pneumococcal vaccination not administered prior to discharge,

reason not specified M

✽ G9281 Screening performed and documentation that vaccination not

indicated/patient refusal M

✽ G9282 Documentation of medical reason(s) for not reporting the

histological type or NSCLC-NOS classification with an explanation
(e.g., biopsy taken for other purposes in a patient with a history of
non-small cell lung cancer or other documented medical reasons)
M
✽ G9283 Non-small-cell lung cancer biopsy and cytology specimen report
documents classification into specific histologic type or classified as
NSCLC-NOS with an explanation M

✽ G9284 Non-small-cell lung cancer biopsy and cytology specimen report

does not document classification into specific histologic type or
classified as NSCLCNOS with an explanation M

✽ G9285 Specimen site other than anatomic location of lung or is not

 classified as non-small-cell lung cancer M

✽ G9286 Antibiotic regimen prescribed within 10 days after onset of

symptoms M

✽ G9287 Antibiotic regimen not prescribed within 10 days after onset of

symptoms M

✽ G9288 Documentation of medical reason(s) for not reporting the

histological type or NSCLC-NOS classification with an explanation
(e.g., a solitary fibrous tumor in a person with a history of non-small
cell carcinoma or other documented medical reasons) M

✽ G9289 Non-small cell lung cancer biopsy and cytology specimen report
documents classification into specific histologic type or classified as
NSCLC-NOS with an explanation M

✽ G9290 Non-small cell lung cancer biopsy and cytology specimen report
does not document classification into specific histologic type or
classified as NSCLCNOS with an explanation M

✽ G9291 Specimen site other than anatomic location of lung, is not classified
as non-small-cell lung cancer or classified as NSCLC-NOS M

✽ G9292 Documentation of medical reason(s) for not reporting PT category

and a statement on thickness and ulceration and for PT1, mitotic rate
(e.g., negative skin biopsies in a patient with a history of melanoma
or other documented medical reasons) M

✽ G9293 Pathology report does not include the PT category and a statement
on thickness and ulceration and for PT1, mitotic rate M

✽ G9294 Pathology report includes the PT category and a statement on

thickness and ulceration and for PT1, mitotic rate M

✽ G9295 Specimen site other than anatomic cutaneous location M

✽ G9296 Patients with documented shared decision-making including

discussion of conservative (non-surgical) therapy (e.g., NSAIDs,
analgesics, weight loss, exercise, injections) prior to the procedure
M
✽ G9297 Shared decision-making including discussion of conservative
(nonsurgical) therapy (e.g., NSAIDs, analgesics, weight loss,
exercise, injections) prior to the procedure not documented, reason
not given M

✽ G9298 Patients who are evaluated for venous thromboembolic and

cardiovascular risk factors within 30 days prior to the procedure
(e.g., history of DVT, PE, MI, arrhythmia and stroke) M

✽ G9299 Patients who are not evaluated for venous thromboembolic and
 cardiovascular risk factors within 30 days prior to the procedure
(e.g., history of DVT, PE, MI, arrhythmia and stroke, reason not
given) M

✽ G9305 Intervention for presence of leak of endoluminal contents through

an anastomosis not required M

✽ G9306 Intervention for presence of leak of endoluminal contents through

an anastomosis required M

✽ G9307 No return to the operating room for a surgical procedure, for

complications of the principal operative procedure, within 30 days
of the principal operative procedure M

✽ G9308 Unplanned return to the operating room for a surgical procedure, for
complications of the principal operative procedure, within 30 days
of the principal operative procedure M

✽ G9309 No unplanned hospital readmission within 30 days of principal

procedure M

✽ G9310 Unplanned hospital readmission within 30 days of principal

procedure M

✽ G9311 No surgical site infection M

✽ G9312 Surgical site infection M

✽ G9313 Amoxicillin, with or without clavulanate, not prescribed as first line

antibiotic at the time of diagnosis for documented reason M

✽ G9314 Amoxicillin, with or without clavulanate, not prescribed as first line

antibiotic at the time of diagnosis, reason not given M

✽ G9315 Amoxicillin, with or without clavulanate, prescribed as a first line

antibiotic at the time of diagnosis M

✽ G9316 Documentation of patient-specific risk assessment with a risk

calculator based on multi-institutional clinical data, the specific risk
calculator used, and communication of risk assessment from risk
calculator with the patient or family M

✽ G9317 Documentation of patient-specific risk assessment with a risk

calculator based on multi-institutional clinical data, the specific risk
calculator used, and communication of risk assessment from risk
calculator with the patient or family not completed M

✽ G9318 Imaging study named according to standardized nomenclature M

✽ G9319 Imaging study not named according to standardized nomenclature,

reason not given M

✽ G9321 Count of previous CT (any type of CT) and cardiac nuclear

medicine (myocardial perfusion) studies documented in the 12-
 month period prior to the current study M

✽ G9322 Count of previous CT and cardiac nuclear medicine (myocardial

perfusion) studies not documented in the 12-month period prior to
the current study, reason not given M

✽ G9341 Search conducted for prior patient CT studies completed at non-

affiliated external healthcare facilities or entities within the past 12-
months and are available through a secure, authorized, media-free,
shared archive prior to an imaging study being performed M

✽ G9342 Search not conducted prior to an imaging study being performed for
prior patient CT studies completed at non-affiliated external
healthcare facilities or entities within the past 12-months and are
available through a secure, authorized, media-free, shared archive,
reason not given M

✽ G9344 Due to system reasons search not conducted for DICOM format
images for prior patient CT imaging studies completed at non-
affiliated external healthcare facilities or entities within the past 12
months that are available through a secure, authorized, media-free,
shared archive (e.g., non-affiliated external healthcare facilities or
entities does not have archival abilities through a shared archival
system) M

✽ G9345 Follow-up recommendations documented according to

recommended guidelines for incidentally detected pulmonary
nodules (e.g., follow-up CT imaging studies needed or that no
follow-up is needed) based at a minimum on nodule size and patient
risk factors M

✽ G9347 Follow-up recommendations not documented according to

recommended guidelines for incidentally detected pulmonary
nodules, reason not given M

✽ G9351 More than one CT scan of the paranasal sinuses ordered or received
within 90 days after diagnosis M

✽ G9352 More than one CT scan of the paranasal sinuses ordered or received
within 90 days after the date of diagnosis, reason not given M

✽ G9353 More than one CT scan of the paranasal sinuses ordered or received
within 90 days after the date of diagnosis for documented reasons
(e.g., patients with complications, second CT obtained prior to
surgery, other medical reasons) M

✽ G9354 One CT scan or no CT scan of the paranasal sinuses ordered within

90 days after the date of diagnosis M

✽ G9355 Elective delivery (without medical indication) by c-section, or early

 induction not performed (less than 39 weeks gestation) M

✽ G9356 Elective delivery (without medical indication) by c-section, or early

induction performed (less than 39 weeks gestation) M

✽ G9357 Post-partum screenings, evaluations and education performed M

✽ G9358 Post-partum screenings, evaluations and education not performed

M
G9359 Documentation of negative or managed positive TB screen with ✖
further evidence that TB is not active prior to the treatment with a
biologic immune response modifier
G9360 No documentation of negative or managed positive TB screen ✖
✽ G9361 Medical indication for induction [delivery by cesarean birth or
induction of labor (<39 weeks of gestation)] [documentation of
reason(s) for elective delivery (e.g., hemorrhage and placental
complications, hypertension, preeclampsia and eclampsia, rupture of
membranes-premature or prolonged, maternal conditions
complicating pregnancy/delivery, fetal conditions complicating
pregnancy/delivery, late pregnancy, prior uterine surgery, or
participation in clinical trial)] M

✽ G9364 Sinusitis caused by, or presumed to be caused by, bacterial infection

M
✽ G9367 At least two orders for high-risk medications from the same drug
class ordered M

✽ G9368 At least two orders for high-risk medications from the same drug
class not ordered M

✽ G9380 Patient offered assistance with end of life issues during the
measurement period M

✽ G9382 Patient not offered assistance with end of life issues during the
measurement period M

✽ G9383 Patient received screening for HCV infection within the 12 month
reporting period M

✽ G9384 Documentation of medical reason(s) for not receiving annual

screening for HCV infection (e.g., decompensated cirrhosis
indicating advanced disease [i.e., ascites, esophageal variceal
bleeding, hepatic encephalopathy], hepatocellular carcinoma,
waitlist for organ transplant, limited life expectancy, other medical
reasons) M

✽ G9385 Documentation of patient reason(s) for not receiving annual

screening for HCV infection (e.g., patient declined, other patient
reasons) M
✽ G9386 Screening for HCV infection not received within the 12 month
reporting period, reason not given M

✽ G9393 Patient with an initial PHQ-9 score greater than nine who achieves
remission at 12 months as demonstrated by a 12 month (+/- 30 days)
PHQ-9 score of less than five M

✽ G9394 Patient who had a diagnosis of bipolar disorder or personality

disorder, death, permanent nursing home resident or receiving
hospice or palliative care any time during the measurement or
assessment period M

✽ G9395 Patient with an initial PHQ-9 score greater than nine who did not
achieve remission at 12 months as demonstrated by a 12 month (+/-
30 days) PHQ-9 score greater than or equal to five M

✽ G9396 Patient with an initial PHQ-9 score greater than nine who was not
assessed for remission at 12 months (+/- 30 days) M

✽ G9402 Patient received follow-up within 30 days after discharge M

✽ G9403 Clinician documented reason patient was not able to complete 30

day follow-up from acute inpatient setting discharge (e.g., patient
death prior to follow-up visit, patient non-compliant for visit follow-
up) M

✽ G9404 Patient did not receive follow-up within 30 days after discharge
M
✽ G9405 Patient received follow-up within 7 days after discharge M

✽ G9406 Clinician documented reason patient was not able to complete 7 day
follow-up from acute inpatient setting discharge (i.e patient death
prior to follow-up visit, patient non-compliance for visit follow-up)
M
✽ G9407 Patient did not receive follow-up within 7 days after discharge M

✽ G9408 Patients with cardiac tamponade and/or pericardiocentesis occurring

within 30 days M

✽ G9409 Patients without cardiac tamponade and/or pericardiocentesis

occurring within 30 days M

✽ G9410 Patient admitted within 180 days, status post CIED implantation,
replacement, or revision with an infection requiring device removal
or surgical revision M

✽ G9411 Patient not admitted within 180 days, status post CIED
implantation, replacement, or revision with an infection requiring
device removal or surgical revision M

✽ G9412 Patient admitted within 180 days, status post CIED implantation,
replacement, or revision with an infection requiring device removal
 or surgical revision M

✽ G9413 Patient not admitted within 180 days, status post CIED
implantation, replacement, or revision with an infection requiring
device removal or surgical revision M

✽ G9414 Patient had one dose of meningococcal vaccine (serogroups a, c, w,

y) on or between the patient’s 11th and 13th birthdays M

✽ G9415 Patient did not have one dose of meningococcal (serogroups a, c, w,

y) vaccine on or between the patient’s 11th and 13th birthdays M

✽ G9416 Patient had one tetanus, diphtheria toxoids and acellular pertussis
vaccine (Tdap) or one tetanus, diphtheria toxoids vaccine (Td) on or
between the patient’s 10th and 13th birthdays M

✽ G9417 Patient did not have one tetanus, diphtheria toxoids and acellular
pertussis vaccine (Tdap) on or between the patient’s 10th and 13th
birthdays M

✽ G9418 Primary non-small cell lung cancer lung biopsy and cytology
specimen report documents classification into specific histologic
type following IASLC guidance or classified as NSCLC-NOS with
an explanation M

✽ G9419 Documentation of medical reason(s) for not including the

histological type or NSCLC-NOS classification with an explanation
(e.g., specimen insufficient or non-diagnostic, specimen does not
contain cancer, other documented medical reasons) M

✽ G9420 Specimen site other than anatomic location of lung or is not

classified as primary non-small cell lung cancer M

✽ G9421 Primary non-small cell lung cancer biopsy and cytology specimen
report does not document classification into specific histologic type
or histologic type does not follow IASLC guidance or is classified
as NSCLC-NOS but without an explanation M

✽ G9422 Primary lung carcinoma resection report documents pT category, pN

category and for non-small cell lung cancer, histologic type (e.g.,
squamous cell carcinoma, adenocarcinoma and not NSCLC-NOS)
M
✽ G9423 Documentation of medical reason for not including pT category, pN
category and histologic type [for patient with appropriate exclusion
criteria (e.g., metastatic disease, benign tumors, malignant tumors
other than carcinomas, inadequate surgical specimens)] M

✽ G9424 Specimen site other than anatomic location of lung, or classified as

NSCLC-NOS M

✽ G9425 Primary lung carcinoma resection report does not document pT

 category, pN category and for non-small cell lung cancer, histologic
type (e.g., squamous cell carcinoma, adenocarcinoma) M

✽ G9426 Improvement in median time from ED arrival to initial ED oral or

parenteral pain medication administration performed for ED
admitted patients M

✽ G9427 Improvement in median time from ED arrival to initial ED oral or

parenteral pain medication administration not performed for ED
admitted patients M

✽ G9428 Pathology report includes the pT category, thickness, ulceration and

mitotic rate, peripheral and deep margin status and presence or
absence of microsatellitosis for invasive tumors M

✽ G9429 Documentation of medical reason(s) for not including pT category,

thickness, ulceration and mitotic rate, peripheral and deep margin
status and presence or absence of microsatellitosis for invasive
tumors (e.g., negative skin biopsies in a patient with a history of
melanoma or other documented medical reasons) M

✽ G9430 Specimen site other than anatomic cutaneous location M

✽ G9431 Pathology report does not include the pT category, thickness,

ulceration and mitotic rate, peripheral and deep margin status and
presence or absence of microsatellitosis for invasive tumors M

✽ G9432 Asthma well-controlled based on the ACT, C-ACT, ACQ, or ATAQ

score and results documented M

✽ G9434 Asthma not well-controlled based on the ACT, C-ACT, ACQ, or

ATAQ score, or specified asthma control tool not used, reason not
given M

✽ G9451 Patient received one-time screening for HCV infection M

✽ G9452 Documentation of medical reason(s) for not receiving one-time

screening for HCV infection (e.g., decompensated cirrhosis
indicating advanced disease [i.e., ascites, esophageal variceal
bleeding, hepatic encephalopathy], hepatocellular carcinoma,
waitlist for organ transplant, limited life expectancy, other medical
reasons) M

✽ G9453 Documentation of patient reason(s) for not receiving one-time

screening for HCV infection (e.g., patient declined, other patient
reasons) M

✽ G9454 One-time screening for HCV infection not received within 12 month
reporting period and no documentation of prior screening for HCV
infection, reason not given M
✽ G9455 Patient underwent abdominal imaging with ultrasound, contrast
enhanced CT or contrast MRI for HCC M

✽ G9456 Documentation of medical or patient reason(s) for not ordering or

performing screening for HCC. medical reason: comorbid medical
conditions with expected survival <5 years, hepatic decompensation
and not a candidate for liver transplantation, or other medical
reasons; patient reasons: patient declined or other patient reasons
(e.g., cost of tests, time related to accessing testing equipment) M

✽ G9457 Patient did not undergo abdominal imaging and did not have a
documented reason for not undergoing abdominal imaging in the
submission period M

✽ G9458 Patient documented as tobacco user and received tobacco cessation

intervention (must include at least one of the following: advice
given to quit smoking or tobacco use, counseling on the benefits of
quitting smoking or tobacco use, assistance with or referral to
external smoking or tobacco cessation support programs, or current
enrollment in smoking or tobacco use cessation program) if
identified as a tobacco user M

✽ G9459 Currently a tobacco non-user M

✽ G9460 Tobacco assessment or tobacco cessation intervention not

performed, reason not given M

✽ G9468 Patient not receiving corticosteroids greater than or equal to 10

mg/day of prednisone equivalents for 60 or greater consecutive days
or a single prescription equating to 600 mg prednisone or greater for
all fills M

✽ G9470 Patients not receiving corticosteroids greater than or equal to 10

mg/day of prednisone equivalents for 60 or greater consecutive days
or a single prescription equating to 600 mg prednisone or greater for
all fills M

✽ G9471 Within the past 2 years, central dual-energy x-ray absorptiometry

(DXA) not ordered or documented M

✽ G9473 Services performed by chaplain in the hospice setting, each 15

minutes B

✽ G9474 Services performed by dietary counselor in the hospice setting, each

15 minutes B

✽ G9475 Services performed by other counselor in the hospice setting, each

15 minutes B

✽ G9476 Services performed by volunteer in the hospice setting, each 15

 minutes B

✽ G9477 Services performed by care coordinator in the hospice setting, each

15 minutes B

✽ G9478 Services performed by other qualified therapist in the hospice

setting, each 15 minutes B

✽ G9479 Services performed by qualified pharmacist in the hospice setting,

each 15 minutes B

✽ G9480 Admission to Medicare Care Choice Model program (MCCM)

B
✽ G9481 Remote in-home visit for the evaluation and management of a new
patient for use only in the Medicare-approved comprehensive care
for joint replacement model, which requires these 3 key
components: a problem focused history; a problem focused
examination; and straightforward medical decision making,
furnished in real time using interactive audio and video technology.
Counseling and coordination of care with other physicians, other
qualified health care professionals or agencies are provided
consistent with the nature of the problem(s) and the needs of the
patient or the family or both. Usually, the presenting problem(s) are
self limited or minor. Typically, 10 minutes are spent with the
patient or family or both via real time, audio and video
intercommunications technology B

✽ G9482 Remote in-home visit for the evaluation and management of a new
patient for use only in the Medicare-approved comprehensive care
for joint replacement model, which requires these 3 key
components: an expanded problem focused history; an expanded
problem focused examination; straightforward medical decision
making, furnished in real time using interactive audio and video
technology. Counseling and coordination of care with other
physicians, other qualified health care professionals or agencies are
provided consistent with the nature of the problem(s) and the needs
of the patient or the family or both. Usually, the presenting
problem(s) are of low to moderate severity. Typically, 20 minutes
are spent with the patient or family or both via real time, audio and
video intercommunications technology B

✽ G9483 Remote in-home visit for the evaluation and management of a new
patient for use only in the Medicare-approved comprehensive care
for joint replacement model, which requires these 3 key
components: a detailed history; a detailed examination; medical
decision making of low complexity, furnished in real time using
 interactive audio and video technology. Counseling and
coordination of care with other physicians, other qualified health
care professionals or agencies are provided consistent with the
nature of the problem(s) and the needs of the patient or the family or
both. Usually, the presenting problem(s) are of moderate severity.
Typically, 30 minutes are spent with the patient or family or both via
real time, audio and video intercommunications technology B

✽ G9484 Remote in-home visit for the evaluation and management of a new
patient for use only in the Medicare-approved comprehensive care
for joint replacement model, which requires these 3 key
components: a comprehensive history; a comprehensive
examination; medical decision making of moderate complexity,
furnished in real time using interactive audio and video technology.
Counseling and coordination of care with other physicians, other
qualified health care professionals or agencies are provided
consistent with the nature of the problem(s) and the needs of the
patient or the family or both. Usually, the presenting problem(s) are
of moderate to high severity. Typically, 45 minutes are spent with
the patient or family or both via real time, audio and video
intercommunications technology B

✽ G9485 Remote in-home visit for the evaluation and management of a new
patient for use only in the Medicare-approved comprehensive care
for joint replacement model, which requires these 3 key
components: a comprehensive history; a comprehensive
examination; medical decision making of high complexity,
furnished in real time using interactive audio and video technology.
Counseling and coordination of care with other physicians, other
qualified health care professionals or agencies are provided
consistent with the nature of the problem(s) and the needs of the
patient or the family or both. Usually, the presenting problem(s) are
of moderate to high severity. Typically, 60 minutes are spent with
the patient or family or both via real time, audio and video
intercommunications technology B

✽ G9486 Remote in-home visit for the evaluation and management of an

established patient for use only in the Medicareapproved
comprehensive care for joint replacement model, which requires at
least 2 of the following 3 key components: a problem focused
history; a problem focused examination; straightforward medical
decision making, furnished in real time using interactive audio and
video technology. Counseling and coordination of care with other
physicians, other qualified health care professionals or agencies are
 provided consistent with the nature of the problem(s) and the needs
of the patient or the family or both. Usually, the presenting
problem(s) are self limited or minor. Typically, 10 minutes are spent
with the patient or family or both via real time, audio and video
intercommunications technology B

✽ G9487 Remote in-home visit for the evaluation and management of an

established patient for use only in the Medicareapproved
comprehensive care for joint replacement model, which requires at
least 2 of the following 3 key components: an expanded problem
focused history; an expanded problem focused examination;
medical decision making of low complexity, furnished in real time
using interactive audio and video technology. Counseling and
coordination of care with other physicians, other qualified health
care professionals or agencies are provided consistent with the
nature of the problem(s) and the needs of the patient or the family or
both. Usually, the presenting problem(s) are of low to moderate
severity. Typically, 15 minutes are spent with the patient or family
or both via real time, audio and video intercommunications
technology B

✽ G9488 Remote in-home visit for the evaluation and management of an

established patient for use only in the Medicareapproved
comprehensive care for joint replacement model, which requires at
least 2 of the following 3 key components: a detailed history; a
detailed examination; medical decision making of moderate
complexity, furnished in real time using interactive audio and video
technology. Counseling and coordination of care with other
physicians, other qualified health care professionals or agencies are
provided consistent with the nature of the problem(s) and the needs
of the patient or the family or both. Usually, the presenting
problem(s) are of moderate to high severity. Typically, 25 minutes
are spent with the patient or family or both via real time, audio and
video intercommunications technology B

✽ G9489 Remote in-home visit for the evaluation and management of an

established patient for use only in the Medicareapproved
comprehensive care for joint replacement model, which requires at
least 2 of the following 3 key components: a comprehensive history;
a comprehensive examination; medical decision making of high
complexity, furnished in real time using interactive audio and video
technology. Counseling and coordination of care with other
physicians, other qualified health care professionals or agencies are
provided consistent with the nature of the problem(s) and the needs
 of the patient or the family or both. Usually, the presenting
problem(s) are of moderate to high severity. Typically, 40 minutes
are spent with the patient or family or both via real time, audio and
video intercommunications technology B

✽ G9490 Comprehensive care for joint replacement model, home visit for
patient assessment performed by clinical staff for an individual not
considered homebound, including, but not necessarily limited to
patient assessment of clinical status, safety/fall prevention,
functional status/ambulation, medication
reconciliation/management, compliance with orders/plan of care,
performance of activities of daily living, and ensuring beneficiary
connections to community and other services. (for use only in the
Medicareapproved CJR model); may not be billed for a 30 day
period covered by a transitional care management code B

✽ G9497 Received instruction from the anesthesiologist or proxy prior to the

day of surgery to abstain from smoking on the day of surgery M

✽ G9498 Antibiotic regimen prescribed M

✽ G9500 Radiation exposure indices documented in final report for procedure

using fluoroscopy M

✽ G9501 Radiation exposure indices not documented in final report for

procedure using fluoroscopy, reason not given M

✽ G9502 Documentation of medical reason for not performing foot exam

(i.e., patients who have had either a bilateral amputation above or
below the knee, or both a left and right amputation above or below
the knee before or during the measurement period) M

✽ G9504 Documented reason for not assessing Hepatitis B virus (HBV) status
(e.g. patient not initiating anti-TNF therapy, patient declined) prior
to initiating anti-TNF therapy M

✽ G9505 Antibiotic regimen prescribed within 10 days after onset of

symptoms for documented medical reason M

G9506 Biologic immune response modifier prescribed ✖

✽ G9507 Documentation that the patient is on a statin medication or has

documentation of a valid contraindication or exception to statin
medications; contraindications/exceptions that can be defined by
diagnosis codes include pregnancy during the measurement period,
active liver disease, rhabdomyolysis, end stage renal disease on
dialysis and heart failure; provider documented
contraindications/exceptions include breastfeeding during the
 measurement period, woman of child-bearing age not actively
taking birth control, allergy to statin, drug interaction (HIV protease
inhibitors, nefazodone, cyclosporine, gemfibrozil, and danazol) and
intolerance (with supporting documentation of trying a statin at least
once within the last 5 years or diagnosis codes for myostitis or toxic
myopathy related to drugs) M

✽ G9508 Documentation that the patient is not on a statin medication M

✽ G9509 Adult patients 18 years of age or older with major depression or

dysthymia who reached remission at 12 months as demonstrated by
a 12 month (+/-60 days) PHQ-9 or PHQ-9m score of less than 5
M
✽ G9510 Adult patients 18 years of age or older with major depression or
dysthymia who did not reach remission at twelve months as
demonstrated by a twelve month (+/-60 days) PHQ-9 or PHQ-9m
score of less than 5. Either PHQ-9 or PHQ-9m score was not
assessed or is greater than or equal to 5 M

✽ G9511 Index event date PHQ-9 score greater than 9 documented during the
12 month denominator identification period M

✽ G9512 Individual had a PDC of 0.8 or greater M

✽ G9513 Individual did not have a PDC of 0.8 or greater M

✽ G9514 Patient required a return to the operating room within 90 days of

surgery M

✽ G9515 Patient did not require a return to the operating room within 90 days
of surgery M

✽ G9516 Patient achieved an improvement in visual acuity, from their

preoperative level, within 90 days of surgery M

✽ G9517 Patient did not achieve an improvement in visual acuity, from their
preoperative level, within 90 days of surgery, reason not given M

✽ G9518 Documentation of active injection drug use M

✽ G9519 Patient achieves final refraction (spherical equivalent) +/-1.0

diopters of their planned refraction within 90 days of surgery M

✽ G9520 Patient does not achieve final refraction (spherical equivalent)

+/-1.0 diopters of their planned refraction within 90 days of surgery
M
✽ G9521 Total number of emergency department visits and inpatient
hospitalizations less than two in the past 12 months M

✽ G9522 Total number of emergency department visits and inpatient

hospitalizations equal to or greater than two in the past 12 months or
patient not screened, reason not given M
✽ G9529 Patient with minor blunt head trauma had an appropriate
indication(s) for a head CT M

✽ G9530 Patient presented within a minor blunt head trauma and had a head
CT ordered for trauma by an emergency care provider M

✽ G9531 Patient has documentation of ventricular shunt, brain tumor,

multisystem trauma, or is currently taking an antiplatelet medication
including: abciximab, anagrelide, cangrelor, cilostazol, clopidogrel,
dipyridamole, eptifibatide, prasugrel, ticlopidine, ticagrelor,
tirofiban, or vorapaxar M

✽ G9533 Patient with minor blunt head trauma did not have an appropriate
indication(s) for a head CT M

✽ G9537 Imaging needed as part of a clinical trial; or other clinician ordered

the study M

✽ G9539 Intent for potential removal at time of placement M

✽ G9540 Patient alive 3 months post procedure M

✽ G9541 Filter removed within 3 months of placement M

✽ G9542 Documented re-assessment for the appropriateness of filter removal

within 3 months of placement M

✽ G9543 Documentation of at least two attempts to reach the patient to

arrange a clinical re-assessment for the appropriateness of filter
removal within 3 months of placement M

✽ G9544 Patients that do not have the filter removed, documented re-
assessment for the appropriateness of filter removal, or
documentation of at least two attempts to reach the patient to
arrange a clinical re-assessment for the appropriateness of filter
removal within 3 months of placement M

✽ G9547 Cystic renal lesion that is simple appearing (Bosniak I or II), or

adrenal lesion less than or equal to 1.0 cm or adrenal lesion greater
than 1.0 cm but less than or equal to 4.0 cm classified as likely
benign by unenhanced CT or washout protocol CT, or MRI with in
and opposed-phase sequences or other equivalent institutional
imaging protocols M

✽ G9548 Final reports for imaging studies stating no follow-up imaging is

recommended M

✽ G9549 Documentation of medical reason(s) that follow-up imaging is

indicated (e.g., patient has lymphadenopathy, signs of metastasis or
an active diagnosis or history of cancer, and other medical
reason(s)) M
✽ G9550 Final reports for imaging studies with follow-up imaging
recommended, or final reports that do not include a specific
recommendation of no follow-up M

✽ G9551 Final reports for imaging studies without an incidentally found

lesion noted M

✽ G9552 Incidental thyroid nodule <1.0 cm noted in report M

✽ G9553 Prior thyroid disease diagnosis M

✽ G9554 Final reports for CT, CTA, MRI or MRA of the chest or neck with
follow-up imaging recommended M

✽ G9555 Documentation of medical reason(s) for recommending follow up

imaging (e.g., patient has multiple endocrine neoplasia, patient has
cervical lymphadenopathy, other medical reason(s)) M

✽ G9556 Final reports for CT, CTA, MRI or MRA of the chest or neck with
follow-up imaging not recommended M

✽ G9557 Final reports for CT, CTA, MRI or MRA studies of the chest or neck
without an incidentally found thyroid nodule <1.0 cm noted or no
nodule found M

✽ G9580 Door to puncture time of 90 minutes or less M

✽ G9582 Door to puncture time of greater than 90 minutes, no reason given

M
✽ G9593 Pediatric patient with minor blunt head trauma classified as low risk
according to the pecarn Prediction Rules M

✽ G9594 Patient presented with a minor blunt head trauma and had a head CT
ordered for trauma by an emergency care provider M

✽ G9595 Patient has documentation of ventricular shunt, brain tumor, or

coagulopathy M

✽ G9596 Pediatric patient had a head CT for trauma ordered by someone

other than an emergency care provider, or was ordered for a reason
other than trauma M

✽ G9597 Pediatric patient with minor blunt head trauma not classified as low
risk according to the pecarn Prediction Rules M

✽ G9598 Aortic aneurysm 5.5-5.9 cm maximum diameter on centerline

formatted CT or minor diameter on axial formatted CT M

✽ G9599 Aortic aneurysm 6.0 cm or greater maximum diameter on centerline

formatted CT or minor diameter on axial formatted CT M

✽ G9603 Patient survey score improved from baseline following treatment

M
✽ G9604 Patient survey results not available M
✽ G9605 Patient survey score did not improve from baseline following
treatment M

✽ G9606 Intraoperative cystoscopy performed to evaluate for lower tract

injury M

✽ G9607 Documented medical reasons for not performing intraoperative

cystoscopy (e.g., urethral pathology precluding cystoscopy, any
patient who has a congenital or acquired absence of the urethra) or
in the case of patient death M

✽ G9608 Intraoperative cystoscopy not performed to evaluate for lower tract

injury M

✽ G9609 Documentation of an order for antiplatelet agents M

✽ G9610 Documentation of medical reason(s) in the patient’s record for not

ordering anti-platelet agents M

✽ G9611 Order for anti-platelet agents was not documented in the patient’s
record, reason not given M

✽ G9612 Photodocumentation of two or more cecal landmarks to establish a

complete examination M

✽ G9613 Documentation of post-surgical anatomy (e.g., right hemicolectomy,

ileocecal resection, etc.) M

✽ G9614 Photodocumentation of less than two cecal landmarks (i.e., no cecal

landmarks or only one cecal landmark) to establish a complete
examination M

G9618 Documentation of screening for uterine malignancy or those ✖

that had an ultrasound and/or endometrial sampling of any kind

G9620 Patient not screened for uterine malignancy, or those that have ✖
not had an ultrasound and/or endometrial sampling of any kind,
reason not given

✽ G9621 Patient identified as an unhealthy alcohol user when screened for

unhealthy alcohol use using a systematic screening method and
received brief counseling M

✽ G9622 Patient not identified as an unhealthy alcohol user when screened

for unhealthy alcohol use using a systematic screening method M

G9623 Documentation of medical reason(s) for not screening for ✖

unhealthy alcohol use (e.g., limited life expectancy, other medical
reasons)

Patient not screened for unhealthy alcohol use using a systematic

✽ G9624 screening method or patient did not receive brief counseling if
identified as an unhealthy alcohol user M

✽ G9625 Patient sustained bladder injury at the time of surgery or discovered

subsequently up to 30 days postsurgery M

✽ G9626 Documented medical reason for not reporting bladder injury (e.g.,
gynecologic or other pelvic malignancy documented, concurrent
surgery involving bladder pathology, injury that occurs during
urinary incontinence procedure, patient death from nonmedical
causes not related to surgery, patient died during procedure without
evidence of bladder injury) M

✽ G9627 Patient did not sustain bladder injury at the time of surgery nor
discovered subsequently up to 30 days postsurgery M
✽ G9628 Patient sustained bowel injury at the time of surgery or discovered
subsequently up to 30 days postsurgery M

✽ G9629 Documented medical reasons for not reporting bowel injury (e.g.,
gynecologic or other pelvic malignancy documented, planned (e.g.,
not due to an unexpected bowel injury) resection and/or re-
anastomosis of bowel, or patient death from non-medical causes not
related to surgery, patient died during procedure without evidence of
bowel injury) M

✽ G9630 Patient did not sustain a bowel injury at the time of surgery nor
discovered subsequently up to 30 days postsurgery M

G9631 Patient sustained ureter injury at the time of surgery or ✖

discovered subsequently up to 30 days post-surgery
G9632 Documented medical reasons for not reporting ureter injury ✖
(e.g., gynecologic or other pelvic malignancy documented,
concurrent surgery involving bladder pathology, injury that occurs
during a urinary incontinence procedure, patient death from
nonmedical causes not related to surgery, patient died during
procedure without evidence of ureter injury)
G9633 Patient did not sustain ureter injury at the time of surgery nor ✖
discovered subsequently up to 30 days post-surgery
✽ G9637 At least two orders for the same high-risk medications M

✽ G9638 At least two orders for the same high-risk medications not ordered
M
✽ G9642 Current smoker (e.g., cigarette, cigar, pipe, e-cigarette or marijuana)
M
✽ G9643 Elective surgery M

✽ G9644 Patients who abstained from smoking prior to anesthesia on the day
of surgery or procedure M

✽ G9645 Patients who did not abstain from smoking prior to anesthesia on the
day of surgery or procedure M

✽ G9646 Patients with 90 day MRS score of 0 to 2 M

✽ G9648 Patients with 90 day MRS score greater than 2 M

✽ G9649 Psoriasis assessment tool documented meeting any one of the

specified benchmarks (e.g., PGA; 5-point or 6-point scale), body
surface area (BSA), psoriasis area and severity index (PASI) and/or
dermatology life quality index) (DLQI)) M

✽ G9651 Psoriasis assessment tool documented not meeting any one of the
specified benchmarks (e.g., (pga; 5-point or 6-point scale), body
 surface area (bsa), psoriasis area and severity index (pasi) and/or
dermatology life quality index) (dlqi)) or psoriasis assessment tool
not documented M

✽ G9654 Monitored anesthesia care (mac) M

✽ G9655 A transfer of care protocol or handoff tool/checklist that includes the

required key handoff elements is used M

✽ G9656 Patient transferred directly from anesthetizing location to PACU or

other non-ICU location M

✽ G9658 A transfer of care protocol or handoff tool/checklist that includes the

required key handoff elements is not used M

✽ G9659 Patients greater than 86 years of age who underwent a screening

colonoscopy and did not have a history of colorectal cancer or valid
medical reason for the colonoscopy, including: iron deficiency
anemia, lower gastrointestinal bleeding, Crohn disease (i.e., regional
enteritis), familial adenomatous polyposis, Lynch syndrome (i.e.,
hereditary non-polyposis colorectal cancer), inflammatory bowel
disease, ulcerative colitis, abnormal finding of gastrointestinal tract,
or changes in bowel habits M

✽ G9660 Documentation of medical reason(s) for a colonoscopy performed

on a patient greater than or equal to 86 years of age (e.g., iron
deficiency anemia, lower gastrointestinal bleeding, Crohn disease
(i.e., regional enteritis), familial history of adenomatous polyposis,
Lynch syndrome (i.e., hereditary non-polyposis colorectal cancer),
inflammatory bowel disease, ulcerative colitis, abnormal finding of
gastrointestinal tract, or changes in bowel habits) M

✽ G9661 Patients greater than or equal to 86 years of age who received a

colonoscopy for an assessment of signs/symptoms of GI tract
illness, and/or because the patient meets high risk criteria, and/or to
follow-up on previously diagnosed advance lesions M

✽ G9662 Previously diagnosed or have a diagnosis of clinical ASCVD,

including ASCVD procedure M

✽ G9663 Any ldl-c laboratory test result >=190 mg/dL M

✽ G9664 Patients who are currently statin therapy users or received an order
(prescription) for statin therapy M

✽ G9665 Patients who are not currently statin therapy users or did not receive
an order (prescription) for statin therapy M

✽ G9674 Patients with clinical ascvd diagnosis M

✽ G9675 Patients who have ever had a fasting or direct laboratory result of
 ldl-c = 190 mg/dl M

✽ G9676 Patients aged 40 to 75 years at the beginning of the measurement

period with type 1 or type 2 diabetes and with an ldl-c result of 70-
189 mg/dl recorded as the highest fasting or direct laboratory test
result in the measurement year or during the two years prior to the
beginning of the measurement period M

✽ G9679 This code is for onsite acute care treatment of a nursing facility
resident with pneumonia; may only be billed once per day per
beneficiary B

✽ G9680 This code is for onsite acute care treatment of a nursing facility
resident with CHF; may only be billed once per day per beneficiary
B
✽ G9681 This code is for onsite acute care treatment of a resident with COPD
or asthma; may only be billed once per day per beneficiary B

✽ G9682 This code is for the onsite acute care treatment a nursing facility
resident with a skin infection; may only be billed once per day per
beneficiary B

✽ G9683 Facility service(s) for the onsite acute care treatment of a nursing
facility resident with fluid or electrolyte disorder. (May only be
billed once per day per beneficiary). This service is for a
demonstration project. B

✽ G9684 This code is for the onsite acute care treatment of a nursing facility
resident for a UTI; may only be billed once per day per beneficiary
B
✽ G9685 Physician service or other qualified health care professional for the
evaluation and management of a beneficiary’s acute change in
condition in a nursing facility. This service is for a demonstration
project. M

✽ G9687 Hospice services provided to patient any time during the

measurement period M

✽ G9688 Patients using hospice services any time during the measurement
period M

✽ G9689 Patient admitted for performance of elective carotid intervention

M
✽ G9690 Patient receiving hospice services any time during the measurement
period M

✽ G9691 Patient had hospice services any time during the measurement
period M

✽ G9692 Hospice services received by patient any time during the

 measurement period M

✽ G9693 Patient use of hospice services any time during the measurement
period M

✽ G9694 Hospice services utilized by patient any time during the

measurement period M

✽ G9695 Long-acting inhaled bronchodilator prescribed M

✽ G9696 Documentation of medical reason(s) for not prescribing a long-

acting inhaled bronchodilator M

✽ G9697 Documentation of patient reason(s) for not prescribing a long-acting

inhaled bronchodilator M

✽ G9698 Documentation of system reason(s) for not prescribing a long-acting

inhaled bronchodilator M

✽ G9699 Long-acting inhaled bronchodilator not prescribed, reason not

otherwise specified M

✽ G9700 Patients who use hospice services any time during the measurement
period M

✽ G9702 Patients who use hospice services any time during the measurement
period M

✽ G9703 Episodes where the patient is taking antibiotics (table 1) in the 30

days prior to the episode date, or had an active prescription on the
episode date M

✽ G9704 AJCC breast cancer stage I: T1 mic or T1a documented M

✽ G9705 AJCC breast cancer stage I: T1b (tumor >0.5 cm but <=1 cm in
greatest dimension) documented M

✽ G9706 Low (or very low) risk of recurrence, prostate cancer M

✽ G9707 Patient received hospice services any time during the measurement
period M

✽ G9708 Women who had a bilateral mastectomy or who have a history of a

bilateral mastectomy or for whom there is evidence of a right and a
left unilateral mastectomy M

✽ G9709 Hospice services used by patient any time during the measurement
period M

✽ G9710 Patient was provided hospice services any time during the
measurement period M

✽ G9711 Patients with a diagnosis or past history of total colectomy or

colorectal cancer M

✽ G9712 Documentation of medical reason(s) for prescribing or dispensing

 antibiotic (e.g., intestinal infection, pertussis, bacterial infection,
Lyme disease, otitis media, acute sinusitis, acute pharyngitis, acute
tonsillitis, chronic sinusitis, infection of the
pharynx/larynx/tonsils/adenoids, prostatitis,
cellulitis/mastoiditis/bone infections, acute lymphadenitis, impetigo,
skin staph infections, pneumonia, gonococcal infections/venereal
disease/syphilis, chlamydia, inflammatory diseases, female
reproductive organs), infections of the kidney, cystitis/UTI, acne,
HIV disease/asymptomatic HIV, cystic fibrosis, disorders of the
immune system, malignancy neoplasms, chronic bronchitis,
emphysema, bronchiectasis, extrinsic allergic alveolitis, chronic
airway obstruction, chronic obstructive asthma, pneumoconiosis and
other lung disease due to external agents, other diseases of the
respiratory system, and tuberculosis M

✽ G9713 Patients who use hospice services any time during the measurement
period M

✽ G9714 Patient is using hospice services any time during the measurement
period M

✽ G9715 Patients who use hospice services any time during the measurement
period M

✽ G9716 BMI is documented as being outside of normal parameters, follow-

up plan is not completed for documented medical reason M

✽ G9717 Documentation stating the patient has had a diagnosis of depression

or has had a diagnosis bipolar disorder M

G9718 Hospice services for patient provided any time during the ✖
measurement period
✽ G9719 Patient is not ambulatory, bed ridden, immobile, confined to chair,
wheelchair bound, dependent on helper pushing wheelchair,
independent in wheelchair or minimal help in wheelchair M

✽ G9720 Hospice services for patient occurred any time during the
measurement period M

✽ G9721 Patient not ambulatory, bed ridden, immobile, confined to chair,

wheelchair bound, dependent on helper pushing wheelchair,
independent in wheelchair or minimal help in wheelchair M

✽ G9722 Documented history of renal failure or baseline serum creatinine > =

4.0 mg/dl; renal transplant recipients are not considered to have
preoperative renal failure, unless, since transplantation the CR has
been or is 4.0 or higher M

✽ G9723 Hospice services for patient received any time during the
 measurement period M

✽ G9724 Patients who had documentation of use of anticoagulant medications

overlapping the measurement year M

✽ G9725 Patients who use hospice services any time during the measurement
period M

✽ G9726 Patient refused to participate M

✽ G9727 Patient unable to complete the LEPF prom at initial evaluation

and/or discharge due to blindness, illiteracy, severe mental
incapacity or language incompatibility and an adequate proxy is not
available M

✽ G9728 Patient refused to participate M

✽ G9729 Patient unable to complete the LEPF prom at initial evaluation

and/or discharge due to blindness, illiteracy, severe mental
incapacity or language incompatibility and an adequate proxy is not
available M

✽ G9730 Patient refused to participate M

✽ G9731 Patient unable to complete the LEPF prom at initial evaluation

and/or discharge due to blindness, illiteracy, severe mental
incapacity or language incompatibility and an adequate proxy is not
available M

✽ G9732 Patient refused to participate M

✽ G9733 Patient unable to complete the low back FS prom at initial

evaluation and/or discharge due to blindness, illiteracy, severe
mental incapacity or language incompatibility and an adequate
proxy is not available M

✽ G9734 Patient refused to participate M

✽ G9735 Patient unable to complete the shoulder FS prom at initial evaluation

and/or discharge due to blindness, illiteracy, severe mental
incapacity or language incompatibility and an adequate proxy is not
available M

✽ G9736 Patient refused to participate M

✽ G9737 Patient unable to complete the elbow/wrist/hand FS prom at initial

evaluation and/or discharge due to blindness, illiteracy, severe
mental incapacity or language incompatibility and an adequate
proxy is not available M

✽ G9740 Hospice services given to patient any time during the measurement
period M
✽ G9741 Patients who use hospice services any time during the measurement
period M

✽ G9744 Patient not eligible due to active diagnosis of hypertension M

✽ G9745 Documented reason for not screening or recommending a follow-up

for high blood pressure M

✽ G9746 Patient has mitral stenosis or prosthetic heart valves or patient has
transient or reversible cause of AF (e.g., pneumonia,
hyperthyroidism, pregnancy, cardiac surgery) M

✽ G9751 Patient died at any time during the 24-month measurement period
M
✽ G9752 Emergency surgery M

✽ G9753 Documentation of medical reason for not conducting a search for

DICOM format images for prior patient CT imaging studies
completed at nonaffiliated external healthcare facilities or entities
within the past 12 months that are available through a secure,
authorized, media-free, shared archive (e.g., trauma, acute
myocardial infarction, stroke, aortic aneurysm where time is of the
essence) M

✽ G9754 A finding of an incidental pulmonary nodule M

✽ G9755 Documentation of medical reason(s) for not including a

recommended interval and modality for follow-up or for no follow-
up, and source of recommendations (e.g., patients with unexplained
fever, immunocompromised patients who are at risk for infection)
M
✽ G9756 Surgical procedures that included the use of silicone oil M

✽ G9757 Surgical procedures that included the use of silicone oil M

✽ G9758 Patient in hospice at any time during the measurement period M

✽ G9760 Patients who use hospice services any time during the measurement
period M

✽ G9761 Patients who use hospice services any time during the measurement
period M

✽ G9762 Patient had at least two HPV vaccines (with at least 146 days
between the two) or three HPV vaccines on or between the patient’s
9th and 13th birthdays M

✽ G9763 Patient did not have at least two HPV vaccines (with at least 146
days between the two) or three HPV vaccines on or between the
patient’s 9th and 13th birthdays M

✽ G9764 Patient has been treated with systemic medication for psoriasis
 vulgaris M

✽ G9765 Documentation that the patient declined change in medication or

alternative therapies were unavailable, has documented
contraindications, or has not been treated with systemic for at least
six consecutive months (e.g., experienced adverse effects or lack of
efficacy with all other therapy options) in order to achieve better
disease control as measured by PGA, BSA, PASI, or DLQI M

✽ G9766 Patients who are transferred from one institution to another with a
known diagnosis of CVA for endovascular stroke treatment M

✽ G9767 Hospitalized patients with newly diagnosed CVA considered for

endovascular stroke treatment M

✽ G9768 Patients who utilize hospice services any time during the
measurement period M

✽ G9769 Patient had a bone mineral density test in the past two years or
received osteoporosis medication or therapy in the past 12 months
M
✽ G9770 Peripheral nerve block (PNB) M

✽ G9771 At least 1 body temperature measurement equal to or greater than

35.5 degrees Celsius (or 95.9 degrees Fahrenheit) achieved within
the 30 minutes immediately before or the 15 minutes immediately
after anesthesia end time M

✽ G9772 Documentation of medical reason(s) for not achieving at least 1

body temperature measurement equal to or greater than 35.5 degrees
Celsius (or 95.9 degrees Fahrenheit) within the 30 minutes
immediately before or the 15 minutes immediately after anesthesia
end time (e.g., emergency cases, intentional hypothermia, etc.) M

✽ G9773 At least 1 body temperature measurement equal to or greater than

35.5 degrees Celsius (or 95.9 degrees Fahrenheit) not achieved
within the 30 minutes immediately before or the 15 minutes
immediately after anesthesia end time, reason not given M

G9774 Patients who have had a hysterectomy ✖

✽ G9775 Patient received at least 2 prophylactic pharmacologic anti-emetic
agents of different classes preoperatively and/or intraoperatively
M
✽ G9776 Documentation of medical reason for not receiving at least 2
prophylactic pharmacologic anti-emetic agents of different classes
preoperatively and/or intraoperatively (e.g., intolerance or other
medical reason) M

✽ G9777 Patient did not receive at least 2 prophylactic pharmacologic

 antiemetic agents of different classes preoperatively and/or
intraoperatively M

G9778 Patients who have a diagnosis of pregnancy at any time during ✖

the measurement period
✽ G9779 Patients who are breastfeeding at any time during the measurement
period M

✽ G9780 Patients who have a diagnosis of rhabdomyolysis at any time during

the measurement period M

✽ G9781 Documentation of medical reason(s) for not currently being a statin

therapy user or receiving an order (prescription) for statin therapy
(e.g., patients with statin-associated muscle symptoms, patients who
are receiving palliative care or hospice care, patients with active
liver disease or hepatic disease or insufficiency, and patients with
end stage renal disease [ESRD]) M

✽ G9782 History of or active diagnosis of familial hypercholesterolemia M

✽ G9784 Pathologists/dermatopathologists providing a second opinion on a

biopsy M

✽ G9785 Pathology report diagnosing cutaneous basal cell carcinoma,

squamous cell carcinoma, or melanoma (to include in situ disease)
sent from the pathologist/dermatopathologist to the biopsying
clinician for review within 7 days from the time when the tissue
specimen was received by the pathologist M

✽ G9786 Pathology report diagnosing cutaneous basal cell carcinoma,

squamous cell carcinoma, or melanoma (to include in situ disease)
was not sent from the pathologist/dermatopathologist to the
biopsying clinician for review within 7 days from the time when the
tissue specimen was received by the pathologist M

✽ G9787 Patient alive as of the last day of the measurement year M

✽ G9788 Most recent bp is less than or equal to 140/90 mm hg M

✽ G9789 Blood pressure recorded during inpatient stays, emergency room

visits, urgent care visits M

✽ G9790 Most recent BP is greater than 140/90 mm hg, or blood pressure not
documented M

✽ G9791 Most recent tobacco status is tobacco free M

✽ G9792 Most recent tobacco status is not tobacco free M

✽ G9793 Patient is currently on a daily aspirin or other antiplatelet M

✽ G9794 Documentation of medical reason(s) for not on a daily aspirin or

 other antiplatelet (e.g., history of gastrointestinal bleed, intra-cranial
bleed, idiopathic thrombocytopenic purpura (ITP), gastric bypass or
documentation of active anticoagulant use during the measurement
period) M

✽ G9795 Patient is not currently on a daily aspirin or other antiplatelet M

✽ G9796 Patient is currently on a statin therapy M

✽ G9797 Patient is not on a statin therapy M

✽ G9805 Patients who use hospice services any time during the measurement
period M

✽ G9806 Patients who received cervical cytology or an HPV test M

✽ G9807 Patients who did not receive cervical cytology or an HPV test M

G9808 Any patients who had no asthma controller medications ✖

dispensed during the measurement year
G9809 Patients who use hospice services any time during the ✖
measurement period
G9810 Patient achieved a pDC of at least 75% for their asthma ✖
controller medication
G9811 Patient did not achieve a pDC of at least 75% for their asthma ✖
controller medication
✽ G9812 Patient died including all deaths occurring during the hospitalization
in which the operation was performed, even if after 30 days, and
those deaths occurring after discharge from the hospital, but within
30 days of the procedure M

✽ G9813 Patient did not die within 30 days of the procedure or during the
index hospitalization M

✽ G9818 Documentation of sexual activity M

✽ G9819 Patients who use hospice services any time during the measurement
period M

✽ G9820 Documentation of a chlamydia screening test with proper follow-up

M
✽ G9821 No documentation of a chlamydia screening test with proper follow-
up M

✽ G9822 Patient who had an endometrial ablation procedure during the year
prior to the index date (exclusive of the index date) M

✽ G9823 Endometrial sampling or hysteroscopy with biopsy and results

documented during the 12 months prior to the index date (exclusive
of the index date) of the endometrial ablation M
✽ G9824 Endometrial sampling or hysteroscopy with biopsy and results not
documented during the 12 months prior to the index date (exclusive
of the index date) of the endometrial ablation M

✽ G9830 HER-2/neu positive M

✽ G9831 AJCC stage at breast cancer diagnosis = II or III M

✽ G9832 AJCC stage at breast cancer diagnosis = I (Ia or Ib) and T-stage at
breast cancer diagnosis does not equal = T1, T1a, T1b M

✽ G9838 Patient has metastatic disease at diagnosis M

✽ G9839 Anti-EGFR monoclonal antibody therapy M

✽ G9840 Ras (KRas and NRas) gene mutation testing performed before
initiation of anti-EGFR MoAb M

✽ G9841 Ras (KRas and NRas) gene mutation testing not performed before
initiation of anti-EGFR MoAb M

✽ G9842 Patient has metastatic disease at diagnosis M

✽ G9843 Ras (KRas and NRas) gene mutation M

✽ G9844 Patient did not receive anti-EGFR monoclonal antibody therapy

M
✽ G9845 Patient received anti-EGFR monoclonal antibody therapy M

✽ G9846 Patients who died from cancer M

✽ G9847 Patient received systemic cancer-directed therapy in the last 14 days

of life M

✽ G9848 Patient did not receive systemic cancer-directed therapy in the last
14 days of life M

✽ G9852 Patients who died from cancer M

✽ G9853 Patient admitted to the ICU in the last 30 days of life M

✽ G9854 Patient was not admitted to the ICU in the last 30 days of life M

✽ G9858 Patient enrolled in hospice M

✽ G9859 Patients who died from cancer M

✽ G9860 Patient spent less than three days in hospice care M

✽ G9861 Patient spent greater than or equal to three days in hospice care
M
✽ G9862 Documentation of medical reason(s) for not recommending at least
a 10 year follow-up interval (e.g., inadequate prep, familial or
personal history of colonic polyps, patient had no adenoma and age
is = 66 years old, or life expectancy <10 years old, other medical
reasons) M
✽ G9868 Receipt and analysis of remote, asynchronous images for
dermatologic and/or ophthalmologic evaluation, for use only in a
medicare-approved cmmi model, less than 10 minutes
✽ G9869 Receipt and analysis of remote, asynchronous images for
dermatologic and/or ophthalmologic evaluation, for use only in a
medicare-approved cmmi model, 10-20 minutes
✽ G9870 Receipt and analysis of remote, asynchronous images for
dermatologic and/or ophthalmologic evaluation, for use only in a
medicare-approved cmmi model, more than 20 minutes
✽ G9873 First Medicare diabetes prevention program (MDPP) core session
was attended by an MDPP beneficiary under the MDPP expanded
model (EM). A core session is an MDPP service that: (1) is
furnished by an MDPP supplier during months 1 through 6 of the
MDPP services period; (2) is approximately 1 hour in length; and
(3) adheres to a CDC-approved DPP curriculum for core sessions.
M
✽ G9874 Four total Medicare diabetes prevention program (MDPP) core
sessions were attended by an MDPP beneficiary under the mdpp
expanded model (EM). A core session is an MDPP service that: (1)
is furnished by an MDPP supplier during months 1 through 6 of the
MDPP services period; (2) is approximately 1 hour in length; and
(3) adheres to a CDC-approved DPP curriculum for core sessions.
M
✽ G9875 Nine total Medicare diabetes prevention program (MDPP) core
sessions were attended by an MDPP beneficiary under the MDPP
expanded model (EM). A core session is an MDPP service that: (1)
is furnished by an MDPP supplier during months 1 through 6 of the
MDPP services period; (2) is approximately 1 hour in length; and
(3) adheres to a CDC-approved DPP curriculum for core sessions.
M
✽ G9876 Two Medicare diabetes prevention program (MDPP) core
maintenance sessions (MS) were attended by an MDPP beneficiary
in months (mo) 7-9 under the mdpp expanded model (EM). A core
maintenance session is an MDPP service that: (1) is furnished by an
MDPP supplier during months 7 through 12 of the MDPP services
period; (2) is approximately 1 hour in length; and (3) adheres to a
CDC-approved DPP curriculum for maintenance sessions. The
beneficiary did not achieve at least 5% weight loss (WL) from
his/her baseline weight, as measured by at least one inperson weight
measurement at a core maintenance session in months 7-9. M

✽ G9877 Two Medicare diabetes prevention program (MDPP) core

 maintenance sessions (MS) were attended by an MDPP beneficiary
in months (mo) 10-12 under the MDPP expanded model (EM). A
core maintenance session is an MDPP service that: (1) is furnished
by an MDPP supplier during months 7 through 12 of the MDPP
services period; (2) is approximately 1 hour in length; and (3)
adheres to a CDC-approved DPP curriculum for maintenance
sessions. The beneficiary did not achieve at least 5% weight loss
(WL) from his/her baseline weight, as measured by at least one in-
person weight measurement at a core maintenance session in
months 10-12. M

✽ G9878 Two Medicare diabetes prevention program (MDPP) core

maintenance sessions (MS) were attended by an MDPP beneficiary
in months (mo) 7-9 under the MDPP expanded model (EM). A core
maintenance session is an MDPP service that: (1) is furnished by an
MDPP supplier during months 7 through 12 of the MDPP services
period; (2) is approximately 1 hour in length; and (3) adheres to a
CDC-approved DPP curriculum for maintenance sessions. The
beneficiary achieved at least 5% weight loss (WL) from his/her
baseline weight, as measured by at least one inperson weight
measurement at a core maintenance session in months 7-9. M

✽ G9879 Two Medicare diabetes prevention program (MDPP) core

maintenance sessions (MS) were attended by an MDPP beneficiary
in months (mo) 10-12 under the MDPP expanded model (EM). A
core maintenance session is an MDPP service that: (1) is furnished
by an MDPP supplier during months 7 through 12 of the MDPP
services period; (2) is approximately 1 hour in length; and (3)
adheres to a CDC-approved DPP curriculum for maintenance
sessions. The beneficiary achieved at least 5% weight loss (WL)
from his/her baseline weight, as measured by at least one in-person
weight measurement at a core maintenance session in months 10-12.
M
✽ G9880 The MDPP beneficiary achieved at least 5% weight loss (WL) from
his/her baseline weight in months (mo) 1-12 of the MDPP services
period under the MDPP expanded model (EM). This is a one-time
payment available when a beneficiary first achieves at least 5%
weight loss from baseline as measured by an in-person weight
measurement at a core session or core maintenance session. M

✽ G9881 The MDPP beneficiary achieved at least 9% weight loss (WL) from
his/her baseline weight in months (mo) 1-24 under the MDPP
expanded model (EM). This is a one-time payment available when a
beneficiary first achieves at least 9% weight loss from baseline as
 measured by an in-person weight measurement at a core session,
core maintenance session, or ongoing maintenance session. M

✽ G9882 Two Medicare diabetes prevention program (MDPP) ongoing

maintenance sessions (MS) were attended by an MDPP beneficiary
in months (mo) 13-15 under the MDPP expanded model (EM). An
ongoing maintenance session is an MDPP service that: (1) is
furnished by an MDPP supplier during months 13 through 24 of the
MDPP services period; (2) is approximately 1 hour in length; and
(3) adheres to a CDC-approved DPP curriculum for maintenance
sessions. The beneficiary maintained at least 5% weight loss (WL)
from his/her baseline weight, as measured by at least one inperson
weight measurement at an ongoing maintenance session in months
13-15. M

✽ G9883 Two Medicare diabetes prevention program (MDPP) ongoing

maintenance sessions (MS) were attended by an MDPP beneficiary
in months (mo) 16-18 under the MDPP expanded model (EM). An
ongoing maintenance session is an MDPP service that: (1) is
furnished by an MDPP supplier during months 13 through 24 of the
MDPP services period; (2) is approximately 1 hour in length; and
(3) adheres to a CDC-approved DPP curriculum for maintenance
sessions. The beneficiary maintained at least 5% weight loss (WL)
from his/her baseline weight, as measured by at least one in-person
weight measurement at an ongoing maintenance session in months
16-18. M

✽ G9884 Two Medicare diabetes prevention program (MDPP) ongoing

maintenance sessions (MS) were attended by an MDPP beneficiary
in months (mo) 19-21 under the MDPP expanded model (EM). An
ongoing maintenance session is an MDPP service that: (1) is
furnished by an MDPP supplier during months 13 through 24 of the
MDPP services period; (2) is approximately 1 hour in length; and
(3) adheres to a CDC-approved DPP curriculum for maintenance
sessions. The beneficiary maintained at least 5% weight loss (WL)
from his/her baseline weight, as measured by at least one in-person
weight measurement at an ongoing maintenance session in months
19-21. M

✽ G9885 Two Medicare diabetes prevention program (MDPP) ongoing

maintenance sessions (MS) were attended by an MDPP beneficiary
in months (mo) 22-24 under the MDPP expanded model (EM). An
ongoing maintenance session is an MDPP service that: (1) is
furnished by an MDPP supplier during months 13 through 24 of the
 MDPP services period; (2) is approximately 1 hour in length; and
(3) adheres to a CDC-approved DPP curriculum for maintenance
sessions. The beneficiary maintained at least 5% weight loss (WL)
from his/her baseline weight, as measured by at least one in-person
weight measurement at an ongoing maintenance session in months
22-24. M

NOTE: The following codes do not imply that codes in other sections are
necessarily covered.

Quality Measures: Miscellaneous

✽ G9890 Bridge payment: a one-time payment for the first Medicare diabetes
prevention program (MDPP) core session, core maintenance
session, or ongoing maintenance session furnished by an MDPP
supplier to an MDPP beneficiary during months 1-24 of the MDPP
expanded model (EM) who has previously received MDPP services
from a different MDPP supplier under the MDPP expanded model.
A supplier may only receive one bridge payment per MDPP
beneficiary. M

✽ G9891 MDPP session reported as a line-item on a claim for a payable

MDPP expanded model (EM) HCPCS code for a session furnished
by the billing supplier under the MDPP expanded model and
counting toward achievement of the attendance performance goal
for the payable MDPP expanded model HCPCS code (this code is
for reporting purposes only) M

✽ G9890 Dilated macular exam performed, including documentation of the

presence or absence of macular thickening or geographic atrophy or
hemorrhage and the level of macular degeneration severity M

✽ G9891 Documentation of medical reason(s) for not performing a dilated

macular examination M

✽ G9892 Documentation of patient reason(s) for not performing a dilated

macular examination M

✽ G9893 Dilated macular exam was not performed, reason not otherwise
specified M

✽ G9894 Androgen deprivation therapy prescribed/administered in

combination with external beam radiotherapy to the prostate M

✽ G9895 Documentation of medical reason(s) for not

prescribing/administering androgen deprivation therapy in
combination with external beam radiotherapy to the prostate (e.g.,
 salvage therapy) M

✽ G9896 Documentation of patient reason(s) for not

prescribing/administering androgen deprivation therapy in
combination with external beam radiotherapy to the prostate M

✽ G9897 Patients who were not prescribed/administered androgen deprivation

therapy in combination with external beam radiotherapy to the
prostate, reason not given M

✽ G9898 Patient age 66 or older in institutional special needs plans (SNP) or

residing in long-term care with pos code 32, 33, 34, 54, or 56 for
more than 90 consecutive days during the measurement period M

✽ G9899 Screening, diagnostic, film, digital or digital breast tomosynthesis

(3D) mammography results documented and reviewed M

✽ G9900 Screening, diagnostic, film, digital or digital breast tomosynthesis

(3D) mammography results were not documented and reviewed,
reason not otherwise specified M

✽ G9901 Patient age 66 or older in institutional special needs plans (SNP) or

residing in long-term care with pos code 32, 33, 34, 54, or 56 for
more than 90 consecutive days during the measurement period M

✽ G9902 Patient screened for tobacco use and identified as a tobacco user
M
✽ G9903 Patient screened for tobacco use and identified as a tobacco non-
user M

G9904 Documentation of medical reason(s) for not screening for ✖

tobacco use (e.g., limited life expectancy, other medical reason)
✽ G9905 Patient not screened for tobacco use M

✽ G9906 Patient identified as a tobacco user received tobacco cessation

intervention during the measurement period or in the six months
prior to the measurement period (counseling and/or
pharmacotherapy) M

G9907 Documentation of medical reason(s) for not providing tobacco

cessation intervention on the date of the encounter or within the ✖
previous 12 months (e.g., limited life expectancy, other medical
reason)

✽ G9908 Patient identified as tobacco user did not receive tobacco cessation
intervention during the measurement period or in the six months
prior to the measurement period (counseling and/or
pharmacotherapy) M

G9909 Documentation of medical reason(s) for not providing tobacco ✖

 cessation intervention on the date of the encounter or within the
previous 12 months if identified as a tobacco user (e.g., limited life
expectancy, other medical reason)
✽ G9910 Patients age 66 or older in institutional special needs plans (SNP) or
residing in long-term care with pos code 32, 33, 34, 54, or 56 for
more than 90 consecutive days during the measurement period M

✽ G9911 Clinically node negative (t1n0m0 or t2n0m0) invasive breast cancer

before or after neoadjuvant systemic therapy M

✽ G9912 Hepatitis B virus (HBV) status assessed and results interpreted prior
to initiating anti-TNF (tumor necrosis factor) therapy M

✽ G9913 Hepatitis B virus (HBV) status not assessed and results interpreted
prior to initiating anti-TNF (tumor necrosis factor) therapy, reason
not otherwise specified M

✽ G9914 Patient receiving an anti-TNF agent M

✽ G9915 No record of HBV results documented M

✽ G9916 Functional status performed once in the last 12 months M

✽ G9917 Documentation of advanced stage dementia and caregiver

knowledge is limited M

✽ G9918 Functional status not performed, reason not otherwise specified

M
✽ G9919 Screening performed and positive and provision of
recommendations M

✽ G9920 Screening performed and negative M

✽ G9921 No screening performed, partial screening performed or positive

screen without recommendations and reason is not given or
otherwise specified M

✽ G9922 Safety concerns screen provided and if positive then documented

mitigation recommendations M

✽ G9923 Safety concerns screen provided and negative M

✽ G9925 Safety concerns screening not provided, reason not otherwise

specified M

✽ G9926 Safety concerns screening positive screen is without provision of

mitigation recommendations, including but not limited to referral to
other resources M

✽ G9927 Documentation of system reason(s) for not prescribing an FDA-

approved anticoagulation due to patient being currently enrolled in a
clinical trial related to af/atrial flutter treatment M

FDA-approved anticoagulant not prescribed, reason not given M

✽ G9928
✽ G9929 Patient with transient or reversible cause of AF (e.g., pneumonia,
hyperthyroidism, pregnancy, cardiac surgery) M

✽ G9930 Patients who are receiving comfort care only M

✽ G9931 Documentation of CHA2DS2-VASc risk score of 0 or 1 for men; or

0, 1, or 2 for women M

G9932 Documentation of patient reason(s) for not having records of ✖

negative or managed positive TB screen (e.g., patient does not
return for mantoux (ppd) skin test evaluation)
✽ G9938 Patients age 66 or older in institutional special needs plans (SNP) or
residing in long-term care with POS code 32, 33, 34, 54, or 56 for
more than 90 consecutive days during the six months prior to the
measurement period through December 31 of the measurement
period M

✽ G9939 Pathologist/dermatopathologist is the same clinician who performed

the biopsy M

✽ G9940 Documentation of medical reason(s) for not on a statin (e.g.,

pregnancy, in vitro fertilization, clomiphene rx, ESRD, cirrhosis,
muscular pain and disease during the measurement period or prior
year) M

G9942 Patient had any additional spine procedures performed on the ✖

same date as the lumbar discectomy/laminectomy
✽ G9943 Back pain was not measured by the visual analog scale (VAS) or
numeric pain scale at three months (6-20 weeks) postoperatively
M
✽ G9945 Patient had cancer, acute fracture or infection related to the lumbar
spine or patient had neuromuscular, idiopathic or congenital lumbar
scoliosis M

✽ G9946 Back pain was not measured by the visual analog scale (VAS) or
numeric pain scale at one year (9 to 15 months) postoperatively
M
G9948 Patient had any additional spine procedures performed on the ✖
same date as the lumbar discectomy/laminectomy
✽ G9949 Leg pain was not measured by the visual analog scale (VAS) or
numeric pain scale at three months (6 to 20 weeks) postoperatively
M
✽ G9954 Patient exhibits 2 or more risk factors for post-operative vomiting
M
✽ G9955 Cases in which an inhalational anesthetic is used only for induction
M
✽ G9956 Patient received combination therapy consisting of at least two
prophylactic pharmacologic anti-emetic agents of different classes
preoperatively and/or intraoperatively M

✽ G9957 Documentation of medical reason for not receiving combination

therapy consisting of at least two prophylactic pharmacologic anti-
emetic agents of different classes preoperatively and/or
intraoperatively (e.g., intolerance or other medical reason) M

✽ G9958 Patient did not receive combination therapy consisting of at least

two prophylactic pharmacologic anti-emetic agents of different
classes preoperatively and/or intraoperatively M

✽ G9959 Systemic antimicrobials not prescribed M

✽ G9960 Documentation of medical reason(s) for prescribing systemic

antimicrobials M

✽ G9961 Systemic antimicrobials prescribed M

✽ G9962 Embolization endpoints are documented separately for each

embolized vessel and ovarian artery angiography or embolization
performed in the presence of variant uterine artery anatomy M

✽ G9963 Embolization endpoints are not documented separately for each

embolized vessel or ovarian artery angiography or embolization not
performed in the presence of variant uterine artery anatomy M

✽ G9964 Patient received at least one well-child visit with a PCP during the
performance period M

✽ G9965 Patient did not receive at least one well-child visit with a PCP
during the performance period M

✽ G9968 Patient was referred to another clinician or specialist during the

performance period M

✽ G9969 Clinician who referred the patient to another clinician received a

report from the provider to whom the patient was referred M

✽ G9970 Clinician who referred the patient to another clinician did not
receive a report from the provider to whom the patient was referred
M
✽ G9974 Dilated macular exam performed, including documentation of the
presence or absence of macular thickening or geographic atrophy or
hemorrhage and the level of macular degeneration severity M

✽ G9975 Documentation of medical reason(s) for not performing a dilated

macular examination M

✽ G9976 Documentation of patient reason(s) for not performing a dilated

macular examination M
✽ G9977 Dilated macular exam was not performed, reason not otherwise
specified M

✽ G9978 Remote in-home visit for the evaluation and management of a new
patient for use only in a Medicare-approved bundled payments for
care improvement advanced (BCPI advanced) model episode of
care, which requires these 3 key components: a problem focused
history; a problem focused examination; and straightforward
medical decision making, furnished in real time using interactive
audio and video technology. Counseling and coordination of care
with other physicians, other qualified health care professionals or
agencies are provided consistent with the nature of the problem(s)
and the needs of the patient or the family or both. Usually, the
presenting problem(s) are self limited or minor. Typically, 10
minutes are spent with the patient or family or both via real time,
audio and video intercommunications technology. B

✽ G9979 Remote in-home visit for the evaluation and management of a new
patient for use only in a Medicare-approved bundled payments for
care improvement advanced (BCPI advanced) model episode of
care, which requires these 3 key components: an expanded problem
focused history; an expanded problem focused examination;
straightforward medical decision making, furnished in real time
using interactive audio and video technology. Counseling and
coordination of care with other physicians, other qualified health
care professionals or agencies are provided consistent with the
nature of the problem(s) and the needs of the patient or the family or
both. Usually, the presenting problem(s) are of low to moderate
severity. Typically, 20 minutes are spent with the patient or family
or both via real time, audio and video intercommunications
technology. B

✽ G9980 Remote in-home visit for the evaluation and management of a new
patient for use only in a Medicare-approved bundled payments for
care improvement advanced (BCPI advanced) model episode of
care, which requires these 3 key components: a detailed history; a
detailed examination; medical decision making of low complexity,
furnished in real time using interactive audio and video technology.
Counseling and coordination of care with other physicians, other
qualified health care professionals or agencies are provided
consistent with the nature of the problem(s) and the needs of the
patient or the family or both. Usually, the presenting problem(s) are
of moderate severity. Typically, 30 minutes are spent with the
patient or family or both via real time, audio and video
 intercommunications technology. B

✽ G9981 Remote in-home visit for the evaluation and management of a new
patient for use only in a Medicare-approved bundled payments for
care improvement advanced (BCPI advanced) model episode of
care, which requires these 3 key components: a comprehensive
history; a comprehensive examination; medical decision making of
moderate complexity, furnished in real time using interactive audio
and video technology. Counseling and coordination of care with
other physicians, other qualified health care professionals or
agencies are provided consistent with the nature of the problem(s)
and the needs of the patient or the family or both. Usually, the
presenting problem(s) are of moderate to high severity. Typically, 45
minutes are spent with the patient or family or both via real time,
audio and video intercommunications technology. B

✽ G9982 Remote in-home visit for the evaluation and management of a new
patient for use only in a Medicare-approved bundled payments for
care improvement advanced (BCPI advanced) model episode of
care, which requires these 3 key components: a comprehensive
history; a comprehensive examination; medical decision making of
high complexity, furnished in real time using interactive audio and
video technology. Counseling and coordination of care with other
physicians, other qualified health care professionals or agencies are
provided consistent with the nature of the problem(s) and the needs
of the patient or the family or both. Usually, the presenting
problem(s) are of moderate to high severity. Typically, 60 minutes
are spent with the patient or family or both via real time, audio and
video intercommunications technology. B

✽ G9983 Remote in-home visit for the evaluation and management of an

established patient for use only in a Medicareapproved bundled
payments for care improvement advanced (BCPI advanced) model
episode of care, which requires at least 2 of the following 3 key
components: a problem focused history; a problem focused
examination; straightforward medical decision making, furnished in
real time using interactive audio and video technology. Counseling
and coordination of care with other physicians, other qualified
health care professionals or agencies are provided consistent with
the nature of the problem(s) and the needs of the patient or the
family or both. Usually, the presenting problem(s) are self limited or
minor. Typically, 10 minutes are spent with the patient or family or
both via real time, audio and video intercommunications technology.
B
✽ G9984 Remote in-home visit for the evaluation and management of an
established patient for use only in a Medicareapproved bundled
payments for care improvement advanced (BCPI advanced) model
episode of care, which requires at least 2 of the following 3 key
components: an expanded problem focused history; an expanded
problem focused examination; medical decision making of low
complexity, furnished in real time using interactive audio and video
technology. Counseling and coordination of care with other
physicians, other qualified health care professionals or agencies are
provided consistent with the nature of the problem(s) and the needs
of the patient or the family or both. Usually, the presenting
problem(s) are of low to moderate severity. Typically, 15 minutes
are spent with the patient or family or both via real time, audio and
video intercommunications technology. B

✽ G9985 Remote in-home visit for the evaluation and management of an

established patient for use only in a Medicareapproved bundled
payments for care improvement advanced (BCPI advanced) model
episode of care, which requires at least 2 of the following 3 key
components: a detailed history; a detailed examination; medical
decision making of moderate complexity, furnished in real time
using interactive audio and video technology. Counseling and
coordination of care with other physicians, other qualified health
care professionals or agencies are provided consistent with the
nature of the problem(s) and the needs of the patient or the family or
both. Usually, the presenting problem(s) are of moderate to high
severity. Typically, 25 minutes are spent with the patient or family
or both via real time, audio and video intercommunications
technology. B

✽ G9986 Remote in-home visit for the evaluation and management of an

established patient for use only in a Medicareapproved bundled
payments for care improvement advanced (BCPI advanced) model
episode of care, which requires at least 2 of the following 3 key
components: a comprehensive history; a comprehensive
examination; medical decision making of high complexity,
furnished in real time using interactive audio and video technology.
Counseling and coordination of care with other physicians, other
qualified health care professionals or agencies are provided
consistent with the nature of the problem(s) and the needs of the
patient or the family or both. Usually, the presenting problem(s) are
of moderate to high severity. Typically, 40 minutes are spent with
the patient or family or both via real time, audio and video
 intercommunications technology. B

✽ G9987 Bundled payments for care improvement advanced (BCPI

advanced) model home visit for patient assessment performed by
clinical staff for an individual not considered homebound, including,
but not necessarily limited to patient assessment of clinical status,
safety/fall prevention, functional status/ambulation, medication
reconciliation/management, compliance with orders/plan of care,
performance of activities of daily living, and ensuring beneficiary
connections to community and other services; for use only for a
BCPI advanced model episode of care; may not be billed for a 30-
day period covered by a transitional care management code. B

✽ G9988 Palliative care services provided to patient any time during the
measurement period M

G9989 Documentation of medical reason(s) for not administering ✖

pneumococcal vaccine (e.g., adverse reaction to vaccine)
✽ G9990 Patient did not receive any pneumococcal conjugate or
polysaccharide vaccine on or after their 60th birthday and before the
end of the measurement period M

✽ G9991 Patient received any pneumococcal conjugate or polysaccharide

vaccine on or after their 60th birthday and before the end of the
measurement period M

✽ G9992 Palliative care services used by patient any time during the
measurement period M

✽ G9993 Patient was provided palliative care services any time during the
measurement period M

✽ G9994 Patient is using palliative care services any time during the
measurement period M

✽ G9995 Patients who use palliative care services any time during the
measurement period M

✽ G9996 Documentation stating the patient has received or is currently

receiving palliative or hospice care M

✽ G9997 Documentation of patient pregnancy anytime during the

measurement period prior to and including the current encounter M
✽ G9998 Documentation of medical reason(s) for an interval of less than 3
years since the last colonoscopy (e.g., last colonoscopy incomplete,
last colonoscopy had inadequate prep, piecemeal removal of
adenomas, last colonoscopy found greater than 10 adenomas, or
patient at high risk for colon cancer [Crohn’s disease, ulcerative
 colitis, lower gastrointestinal bleeding, personal or family history of
colon cancer, hereditary colorectal cancer syndromes]) M

✽ G9999 Documentation of system reason(s) for an interval of less than 3

years since the last colonoscopy (e.g., unable to locate previous
colonoscopy report, previous colonoscopy report was incomplete)
M

BEHAVIORAL HEALTH AND/OR SUBSTANCE ABUSE

TREATMENT SERVICES (H0001-H9999)
NOTE: Used by Medicaid state agencies because no national code exists to meet
the reporting needs of these agencies.
H0001 Alcohol and/or drug assessment
H0002 Behavioral health screening to determine eligibility for admission to
treatment program
H0003 Alcohol and/or drug screening; laboratory analysis of specimens for
presence of alcohol and/or drugs
H0004 Behavioral health counseling and therapy, per 15 minutes
H0005 Alcohol and/or drug services; group counseling by a clinician
H0006 Alcohol and/or drug services; case management
H0007 Alcohol and/or drug services; crisis intervention (outpatient)
H0008 Alcohol and/or drug services; sub-acute detoxification (hospital
inpatient)
H0009 Alcohol and/or drug services; acute detoxification (hospital
inpatient)
H0010 Alcohol and/or drug services; sub-acute detoxification (residential
addiction program inpatient)
H0011 Alcohol and/or drug services; acute detoxification (residential
addiction program inpatient)
H0012 Alcohol and/or drug services; sub-acute detoxification (residential
addiction program outpatient)
H0013 Alcohol and/or drug services; acute detoxification (residential
addiction program outpatient)

H0014 Alcohol and/or drug services; ambulatory detoxification

H0015 Alcohol and/or drug services; intensive outpatient (treatment

 program that operates at least 3 hours/day and at least 3 days/week
and is based on an individualized treatment plan), including
assessment, counseling; crisis intervention, and activity therapies or
education
H0016 Alcohol and/or drug services; medical/somatic (medical intervention
in ambulatory setting)
H0017 Behavioral health; residential (hospital residential treatment
program), without room and board, per diem
H0018 Behavioral health; short-term residential (non-hospital residential
treatment program), without room and board, per diem
H0019 Behavioral health; long-term residential (non-medical, non-acute
care in a residential treatment program where stay is typically longer
than 30 days), without room and board, per diem
H0020 Alcohol and/or drug services; methadone administration and/or
service (provision of the drug by a licensed program)
H0021 Alcohol and/or drug training service (for staff and personnel not
employed by providers)
H0022 Alcohol and/or drug intervention service (planned facilitation)
H0023 Behavioral health outreach service (planned approach to reach a
targeted population)
H0024 Behavioral health prevention information dissemination service
(one-way direct or non-direct contact with service audiences to
affect knowledge and attitude)
H0025 Behavioral health prevention education service (delivery of services
with target population to affect knowledge, attitude and/or behavior)
H0026 Alcohol and/or drug prevention process service, community-based
(delivery of services to develop skills of impactors)
H0027 Alcohol and/or drug prevention environmental service (broad range
of external activities geared toward modifying systems in order to
mainstream prevention through policy and law)
H0028 Alcohol and/or drug prevention problem identification and referral
service (e.g., student assistance and employee assistance programs),
does not include assessment
H0029 Alcohol and/or drug prevention alternatives service (services for
populations that exclude alcohol and other drug use, e.g., alcohol-
free social events)
H0030 Behavioral health hotline service
H0031 Mental health assessment, by nonphysician
H0032 Mental health service plan development by non-physician
H0033 Oral medication administration, direct observation
H0034 Medication training and support, per 15 minutes
H0035 Mental health partial hospitalization, treatment, less than 24 hours
H0036 Community psychiatric supportive treatment, face-to-face, per 15
minutes
H0037 Community psychiatric supportive treatment program, per diem
H0038 Self-help/peer services, per 15 minutes
H0039 Assertive community treatment, face-to-face, per 15 minutes
H0040 Assertive community treatment program, per diem
H0041 Foster care, child, non-therapeutic, per diem
H0042 Foster care, child, non-therapeutic, per month
H0043 Supported housing, per diem
H0044 Supported housing, per month
H0045 Respite care services, not in the home, per diem
H0046 Mental health services, not otherwise specified
H0047 Alcohol and/or other drug abuse services, not otherwise specified
H0048 Alcohol and/or other drug testing: collection and handling only,
specimens other than blood
H0049 Alcohol and/or drug screening
H0050 Alcohol and/or drug services, brief intervention, per 15 minutes
H1000 Prenatal care, at-risk assessment ♀
H1001 Prenatal care, at-risk enhanced service; antepartum management ♀
H1002 Prenatal care, at-risk enhanced service; care coordination ♀
H1003 Prenatal care, at-risk enhanced service; education ♀
H1004 Prenatal care, at-risk enhanced service; follow-up home visit ♀
H1005 Prenatal care, at-risk enhanced service package (includes H1001-
H1004) ♀
H1010 Non-medical family planning education, per session
H1011 Family assessment by licensed behavioral health professional for
state defined purposes
H2000 Comprehensive multidisciplinary evaluation
 H2001 Rehabilitation program, per 1/2 day
H2010 Comprehensive medication services, per 15 minutes
H2011 Crisis intervention service, per 15 minutes
H2012 Behavioral health day treatment, per hour
H2013 Psychiatric health facility service, per diem
H2014 Skills training and development, per 15 minutes
H2015 Comprehensive community support services, per 15 minutes
H2016 Comprehensive community support services, per diem
H2017 Psychosocial rehabilitation services, per 15 minutes
H2018 Psychosocial rehabilitation services, per diem
H2019 Therapeutic behavioral services, per 15 minutes
H2020 Therapeutic behavioral services, per diem
H2021 Community-based wrap-around services, per 15 minutes
H2022 Community-based wrap-around services, per diem
H2023 Supported employment, per 15 minutes
H2024 Supported employment, per diem
H2025 Ongoing support to maintain employment, per 15 minutes
H2026 Ongoing support to maintain employment, per diem
H2027 Psychoeducational service, per 15 minutes
H2028 Sexual offender treatment service, per 15 minutes
H2029 Sexual offender treatment service, per diem
H2030 Mental health clubhouse services, per 15 minutes
H2031 Mental health clubhouse services, per diem
H2032 Activity therapy, per 15 minutes
H2033 Multisystemic therapy for juveniles, per 15 minutes
H2034 Alcohol and/or drug abuse halfway house services, per diem
H2035 Alcohol and/or other drug treatment program, per hour
H2036 Alcohol and/or other drug treatment program, per diem
H2037 Developmental delay prevention activities, dependent child of
client, per 15 minutes

DRUGS OTHER THAN CHEMOTHERAPY DRUGS (J0100-

J8999)
Injection
❂ J0120 Injection, tetracycline, up to 250 mg N1 N

Other: Achromycin
IOM: 100-02, 15, 50
✽ J0121 Injection, omadacycline, 1 mg K2 G

✽ J0122 Injection, eravacycline, 1 mg K2 K

✽ J0129 Injection, abatacept, 10 mg (Code may be used for Medicare when

drug administered under the direct supervision of a physician, not
for use when drug is self-administered) K2 K

Other: Orencia
❂ J0130 Injection, abciximab, 10 mg N1 N

Other: ReoPro
IOM: 100-02, 15, 50
✽ J0131 Injection, acetaminophen, not otherwise specified, 10 mg
N1 N
Other: Ofirmev
Coding Clinic: 2012, Q1, P9
✽ J0132 Injection, acetylcysteine, 100 mg N1 N

Other: Acetadote
✽ J0133 Injection, acyclovir, 5 mg N1 N

▶ J0134 Injection, acetaminophen (fresenius kabi) not therapeutically

equivalent to J0131, 10 mg N

✽ J0135 Injection, adalimumab, 20 mg K2 K

Other: Humira
IOM: 100-02, 15, 50
▶ J0136 Injection, acetaminophen (b braun) not therapeutically equivalent to
J0131, 10 mg N

❂ J0153 Injection, adenosine, 1 mg (not to be used to report any adenosine

phosphate compounds) N1 N

Other: Adenocard, Adenoscan

❂ J0171 Injection, adrenalin, epinephrine, 0.1 mg N1 N

Other: AUVI-Q, Sus-Phrine

IOM: 100-02, 15, 50
Coding Clinic: 2011, Q1, P8
 J0172 Injection, aducanumab-avwa, 2 mg K2 K

▶ J0173 Injection, epinephrine (belcher) not therapeutically equivalent to

J0171, 0.1 mg N

✽ J0178 Injection, aflibercept, 1 mg K2 K

Other: Eylea
✽ J0179 Injection, brolucizumab-dbll, 1 mg K2 K

✽ J0180 Injection, agalsidase beta, 1 mg K2 K

Other: Fabrazyme
IOM: 100-02, 15, 50
✽ J0185 Injection, aprepitant, 1 mg G

Other: Emend
❂ J0190 Injection, biperiden lactate, per 5 mg E2

Other: Akineton
IOM: 100-02, 15, 50
❂ J0200 Injection, alatrofloxacin mesylate, 100 mg E2

Other: Trovan
IOM: 100-02, 15, 50
✽ J0202 Injection, alemtuzumab, 1 mg K2 K

Other: Lemtrada
❂ J0205 Injection, alglucerase, per 10 units E2

Other: Ceredase
IOM: 100-02, 15, 50
❂ J0207 Injection, amifostine, 500 mg K2 K

Other: Ethyol
IOM: 100-02, 15, 50
❂ J0210 Injection, methyldopate HCL, up to 250 mg N1 N

Other: Aldomet
IOM: 100-02, 15, 50
✽ J0215 Injection, alefacept, 0.5 mg E2

✽ J0220 Injection, alglucosidase alfa, not otherwise specified, 10 mg

K2 K
Coding Clinic: 2013: Q2, P5; 2012, Q1, P9
✽ J0221 Injection, alglucosidase alfa, (lumizyme), 10 mg K2 K
Coding Clinic: 2013: Q2, P5
✽ J0222 Injection, patisiran, 0.1 mg K2 G
✽ J0223 Injection, givosiran, 0.5 mg K2

✽ J0224 Injection, lumasiran, 0.5 mg K2 G

▶ J0225 Injection, vutrisiran, 1 mg K2 G

❂ J0256 Injection, alpha 1-proteinase inhibitor (human), not otherwise

specified, 10 mg K2 K

Other: Prolastin, Zemaira

IOM: 100-02, 15, 50
Coding Clinic: 2012, Q1, P9
❂ J0257 Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg
K2 K

IOM: 100-02, 15, 50

Coding Clinic: 2012, Q1, P8
❂ J0270 Injection, alprostadil, per 1.25 mcg (Code may be used for Medicare
when drug administered under the direct supervision of a physician,
not for use when drug is self-administered) B

Other: Caverject, Prostaglandin E1, Prostin VR Pediatric

IOM: 100-02, 15, 50
❂ J0275 Alprostadil urethral suppository (Code may be used for Medicare
when drug administered under the direct supervision of a physician,
not for use when drug is self-administered) B

Other: Muse
IOM: 100-02, 15, 50
✽ J0278 Injection, amikacin sulfate, 100 mg N1 N

❂ J0280 Injection, aminophylline, up to 250 mg N1 N

IOM: 100-02, 15, 50

❂ J0282 Injection, amiodarone hydrochloride, 30 mg N1 N

Other: Cordarone
IOM: 100-02, 15, 50
▶ J0283 Injection, amiodarone hydrochloride (nexterone), 30 mg N

❂ J0285 Injection, amphotericin B, 50 mg N1 N

Other: ABLC, Amphocin, Fungizone

IOM: 100-02, 15, 50
❂ J0287 Injection, amphotericin B lipid complex, 10 mg K2 K

Other: Abelcet
IOM: 100-02, 15, 50
❂ J0288 Injection, amphotericin B cholesteryl sulfate complex, 10 mg
E2

IOM: 100-02, 15, 50

❂ J0289 Injection, amphotericin B liposome, 10 mg K2 K

Other: AmBisome
IOM: 100-02, 15, 50
❂ J0290 Injection, ampicillin sodium, 500 mg N1 N

Other: Omnipen-N, Polycillin-N, Totacillin-N

IOM: 100-02, 15, 50
✽ J0291 Injection, plazomicin, 5 mg K2 G

❂ J0295 Injection, ampicillin sodium/sulbactam sodium, per 1.5 gm

N1 N
Other: Omnipen-N, Polycillin-N, Totacillin-N, Unasyn
IOM: 100-02, 15, 50
❂ J0300 Injection, amobarbital, up to 125 mg K2 K

Other: Amytal
IOM: 100-02, 15, 50
❂ J0330 Injection, succinylcholine chloride, up to 20 mg N1 N

Other: Anectine, Quelicin, Surostrin

IOM: 100-02, 15, 50
✽ J0348 Injection, anidulafungin, 1 mg N1 N

Other: Eraxis
❂ J0350 Injection, anistreplase, per 30 units E2

Other: Eminase
IOM: 100-02, 15, 50
❂ J0360 Injection, hydralazine hydrochloride, up to 20 mg N1 N

Other: Apresoline
IOM: 100-02, 15, 50
✽ J0364 Injection, apomorphine hydrochloride, 1 mg E2

❂ J0365 Injection, aprotinin, 10,000 KIU E2

IOM: 100-02, 15, 50

❂ J0380 Injection, metaraminol bitartrate, per 10 mg N1 N

Other: Aramine
IOM: 100-02, 15, 50
Injection, chloroquine hydrochloride, up to 250 mg
❂ J0390 Benefit only for diagnosed malaria or amebiasis N1 N

Other: Aralen
IOM: 100-02, 15, 50
❂ J0395 Injection, arbutamine HCL, 1 mg E2

IOM: 100-02, 15, 50

✽ J0400 Injection, aripiprazole, intramuscular, 0.25 mg K2 K

✽ J0401 Injection, aripiprazole, extended release, 1 mg K2 K

Other: Abilify Maintena

❂ J0456 Injection, azithromycin, 500 mg N1 N

Other: Zithromax
IOM: 100-02, 15, 50
❂ J0461 Injection, atropine sulfate, 0.01 mg N1 N

IOM: 100-02, 15, 50

❂ J0470 Injection, dimercaprol, per 100 mg K2 K

Other: BAL In Oil

IOM: 100-02, 15, 50
❂ J0475 Injection, baclofen, 10 mg K2 K

Other: Gablofen, Lioresal

IOM: 100-02, 15, 50
❂ J0476 Injection, baclofen 50 mcg for intrathecal trial K2 K

Other: Gablofen, Lioresal

IOM: 100-02, 15, 50
❂ J0480 Injection, basiliximab, 20 mg K2 K

Other: Simulect
IOM: 100-02, 15, 50
✽ J0485 Injection, belatacept, 1 mg K2 K

Other: Nulojix
✽ J0490 Injection, belimumab, 10 mg K2 K

Other: Benlysta
Coding Clinic: 2012, Q1, P9
❂ J0500 Injection, dicyclomine HCL, up to 20 mg N1 N

Other: Antispas, Bentyl, Dibent, Dilomine, Di-Spaz, Neoquess, Or-

Tyl, Spasmoject
IOM: 100-02, 15, 50
❂ J0515 Injection, benztropine mesylate, per 1 mg N1 N

Other: Cogentin
IOM: 100-02, 15, 50
✽ J0517 Injection, benralizumab, 1 mg G

Other: Fasenra
❂ J0520 Injection, bethanechol chloride, myotonachol or urecholine, up to 5
mg E2

IOM: 100-02, 15, 50

✽ J0558 Injection, penicillin G benzathine and penicillin G procaine,
100,000 units N1 N

Other: Bicillin C-R

Coding Clinic: 2011, Q1, P8
❂ J0561 Injection, penicillin G benzathine, 100,000 units K2 K

Other: Bicillin L-A, Permapen

IOM: 100-02, 15, 50
Coding Clinic: 2013: Q2, P3; 2011, Q1, P8
✽ J0565 Injection, bezlotoxumab, 10 mg K2 G

✽ J0567 Injection, cerliponase alfa, 1 mg G

Other: Brineura
✽ J0570 Buprenorphine implant, 74.2 mg K2 G

Other: Probuphine System Kit

Coding Clinic: 2017, Q1, P9
❂ J0571 Buprenorphine, oral, 1 mg E1

❂ J0572 Buprenorphine/naloxone, oral, less than or equal to 3 mg

buprenorphine E1

❂ J0573 Buprenorphine/naloxone, oral, greater than 3 mg, but less than or

equal to 6 mg buprenorphine E1

❂ J0574 Buprenorphine/naloxone, oral, greater than 6 mg, but less than or

equal to 10 mg buprenorphine E1

❂ J0575 Buprenorphine/naloxone, oral, greater than 10 mg buprenorphine

E1

✽ J0583 Injection, bivalirudin, 1 mg N1 N

Other: Angiomax
✽ J0584 Injection, burosumab-twza 1 mg K

Other: Crysvita
❂ J0585 Injection, onabotulinumtoxinaA, 1 unit K2 K

Other: Botox, Botox Cosmetic, Oculinum

IOM: 100-02, 15, 50
✽ J0586 Injection, abobotulinumtoxinaA, 5 units K2 K

❂ J0587 Injection, rimabotulinumtoxinB, 100 units K2 K

Other: Myobloc, Nplate

IOM: 100-02, 15, 50
✽ J0588 Injection, incobotulinumtoxin A, 1 unit K2 K

Other: Xeomin
Coding Clinic: 2012, Q1, P9
✽ J0591 Injection, deoxycholic acid, 1 mg E1

❂ J0592 Injection, buprenorphine hydrochloride, 0.1 mg N1 N

Other: Buprenex
IOM: 100-02, 15, 50
✽ J0593 Injection, lanadelumab-flyo, 1 mg (Code may be used for Medicare
when drug administered under direct supervision of a physician, not
for use when drug is self-administered) K2 K

✽ J0594 Injection, busulfan, 1 mg K2 K

Other: Myleran
✽ J0595 Injection, butorphanol tartrate, 1 mg N1 N

✽ J0596 Injection, C1 esterase inhibitor (recombinant), ruconest, 10 units

K2 K

✽ J0597 Injection, C-1 esterase inhibitor (human), Berinert, 10 units

K2 K
Coding Clinic: 2011, Q1, P7
✽ J0598 Injection, C1 esterase inhibitor (human), cinryze, 10 units
K2 K
✽ J0599 Injection, c-1 esterase inhibitor (human), (haegarda), 10 units G

Other: Berinert
❂ J0600 Injection, edetate calcium disodium, up to 1000 mg
K2 K
Other: Calcium Disodium Versenate
IOM: 100-02, 15, 50
❂ J0604 Cinacalcet, oral, 1 mg, (for ESRD on dialysis) B

❂ J0606 Injection, etelcalcetide, 0.1 mg K2 K

❂ J0610 Injection, calcium gluconate (fresenius kabi), per 10 ml

N1 N
 Other: Kaleinate
IOM: 100-02, 15, 50
▶ J0611 Injection, calcium gluconate (wg critical care), per 10 ml N

❂ J0620 Injection, calcium glycerophosphate and calcium lactate, per 10 ml

N1 N

Other: Calphosan
MCM: 2049
IOM: 100-02, 15, 50
❂ J0630 Injection, calcitonin (salmon), up to 400 units K2 K

Other: Calcimar, Calcitonin-salmon, Miacalcin

IOM: 100-02, 15, 50
❂ J0636 Injection, calcitriol, 0.1 mcg N1 N

Non-dialysis use
Other: Calcijex
IOM: 100-02, 15, 50
✽ J0637 Injection, caspofungin acetate, 5 mg K2 K

Other: Cancidas, Caspofungin

✽ J0638 Injection, canakinumab, 1 mg K2 K

Other: Ilaris
❂ J0640 Injection, leucovorin, calcium, per 50 mg N1 N

Other: Wellcovorin
IOM: 100-02, 15, 50
Coding Clinic: 2009, Q1, P10
❂ J0641 Injection, levoleucovorin, not otherwise specified, 0.5 mg
K2 K
Part of treatment regimen for osteosarcoma
✽ J0642 Injection, levoleucovorin, (khapzory), 0.5 mg K2 G

❂ J0670 Injection, mepivacaine HCL, per 10 ml N1 N

Other: Carbocaine, Isocaine HCl, Polocaine

IOM: 100-02, 15, 50
▶ J0689 Injection, cefazolin sodium (baxter), not therapeutically equivalent
to J0690, 500 mg N

❂ J0690 Injection, cefezolin sodium, 500 mg N1 N

Other: Ancef, Kefzol, Zolicef

IOM: 100-02, 15, 50
✽ J0691 Injection, lefamulin, 1 mg K2 G

✽ J0692 Injection, cefepime HCL, 500 mg N1 N

Other: Maxipime
❂ J0694 Injection, cefoxitin sodium, 1 gm N1 N

Other: Mefoxin
IOM: 100-02, 15, 50,
Cross Reference Q0090
✽ J0695 Injection, ceftolozane 50 mg and tazobactam25 mg
K2 K
Other: Zerbaxa
❂ J0696 Injection, ceftriaxone sodium, per 250 mg N1 N

Other: Rocephin
IOM: 100-02, 15, 50
❂ J0697 Injection, sterile cefuroxime sodium, per 750 mg N1 N

Other: Kefurox, Zinacef

IOM: 100-02, 15, 50
❂ J0698 Injection, cefotaxime sodium, per gm N1 N

Other: Claforan
IOM: 100-02, 15, 50
❂ J0699 Injection, cefiderocol, 10 mg G

▶ J0701 Injection, cefepime hydrochloride (baxter), not therapeutically

equivalent to maxipime, 500 mg N

❂ J0702 Injection, betamethasone acetate 3 mg and betamethasone sodium

phosphate 3 mg N1 N

Other: Betameth, Celestone Soluspan, Selestoject

IOM: 100-02, 15, 50
Coding Clinic: 2018, Q4, P6
▶ J0703 Injection, cefepime hydrochloride (b braun), not therapeutically
equivalent to maxipime, 500 mg N

✽ J0706 Injection, caffeine citrate, 5 mg N1 N

Other: Cafcit, Cipro IV, Ciprofloxacin

❂ J0710 Injection, cephapirin sodium, up to 1 gm E2

Other: Cefadyl
IOM: 100-02, 15, 50
✽ J0712 Injection, ceftaroline fosamil, 10 mg K2 K

Other: Teflaro
 Coding Clinic: 2012, Q1, P9
❂ J0713 Injection, ceftazidime, per 500 mg N1 N

Other: Fortaz, Tazicef

IOM: 100-02, 15, 50
✽ J0714 Injection, ceftazidime and avibactam, 0.5 g/0.125 g
K2 K
❂ J0715 Injection, ceftizoxime sodium, per 500 mg N1 N

IOM: 100-02, 15, 50

✽ J0716 Injection, centruroides immune F(ab)2, up to 120 milligrams
K2 K
Other: Anascorp
✽ J0717 Injection, certolizumab pegol, 1 mg (Code may be used for
Medicare when drug administered under the direct supervision of a
physician, not for use when drug is self-administered)
K2 K
Other: Cimzia
❂ J0720 Injection, chloramphenicol sodium succinate, up to 1 gm
N1 N
Other: Chloromycetin Sodium Succinate
IOM: 100-02, 15, 50
❂ J0725 Injection, chorionic gonadotropin, per 1,000 USP units
Other: A.P.L., Chorex-5, Chorex-10, Chorignon, Choron-10, N1 N
Chorionic Gonadotropin, Choron 10, Corgonject-5, Follutein,
Glukor, Gonic, Novarel, Pregnyl, Profasi HP
IOM: 100-02, 15, 50
❂ J0735 Injection, clonidine hydrochloride (HCL), 1 mg N1 N

Other: Duraclon
IOM: 100-02, 15, 50
▶ J0739 Injection, cabotegravir, 1 mg N

❂ J0740 Injection, cidofovir, 375 mg K2 K

Other: Vistide
IOM: 100-02, 15, 50
❂ J0741 Injection, cabotegravir and rilpivirine, 2mg/3mg K2 G

❂ J0742 Injection, imipenem 4 mg, cilastatin 4 mg and relebactam 2 mg

K2 G
❂ J0743 Injection, cilastatin sodium; imipenem, per 250 mg
N1 N
Other: Primaxin
IOM: 100-02, 15, 50
Injection, ciprofloxacin for intravenous infusion, 200 mg
✽ J0744 N1 N

❂ J0745 Injection, codeine phosphate, per 30 mg N1 N

IOM: 100-02, 15, 50

❂ J0770 Injection, colistimethate sodium, up to 150 mg N1 N

Other: Coly-Mycin M
IOM: 100-02, 15, 50
✽ J0775 Injection, collagenase, clostridium histolyticum, 0.01 mg
K2 K
Other: Xiaflex
Coding Clinic: 2011, Q1, P7
❂ J0780 Injection, prochlorperazine, up to 10 mg N1 N

Other: Compa-Z, Compazine, Cotranzine, Ultrazine-10

IOM: 100-02, 15, 50
❂ J0791 Injection, crizanlizumab-tmca, 5 mg K2 G

❂ J0795 Injection, corticorelin ovine triflutate, 1 mcg K2 K

Other: Acthrel
IOM: 100-02, 15, 50
❂ J0800 Injection, corticotropin, up to 40 units K2 K

Other: ACTH, Acthar

IOM: 100-02, 15, 50
✽ J0834 Injection, cosyntropin, 0.25 mg N1 N

✽ J0840 Injection, crotalidae polyvalent immune fab (ovine), up to 1 gram

K2 K

Other: Crofab
Coding Clinic: 2012, Q1, P9
✽ J0841 Injection, crotalidae immune f(ab’)2 (equine), 120 mg K

Other: Anavip
❂ J0850 Injection, cytomegalovirus immune globulin intravenous (human),
per vial K2 K

Prophylaxis to prevent cytomegalovirus disease associated with

transplantation of kidney, lung, liver, pancreas, and heart.
Other: Cytogam
IOM: 100-02, 15, 50
✽ J0875 Injection, dalbavancin, 5 mg K2 K

Other: Dalvance
▶ J0877 Injection, daptomycin (hospira), not therapeutically equivalent to
J0878, 1 mg N

✽ J0878 Injection, daptomycin, 1 mg K2 K

Other: Cubicin
❂ J0881 Injection, darbepoetin alfa, 1 mcg (non-ESRD use)
K2 K
Other: Aranesp
❂ J0882 Injection, darbepoetin alfa, 1 mcg (for ESRD on dialysis)
K2 K
Other: Aranesp
IOM: 100-02, 6, 10; 100-04, 4, 240
❂ J0883 Injection, argatroban, 1 mg (for non-ESRD use) K2 K

IOM: 100-02, 15, 50

❂ J0884 Injection, argatroban, 1 mg (for ESRD on dialysis) K2 K

IOM: 100-02, 15, 50

❂ J0885 Injection, epoetin alfa, (for non-ESRD use), 1000 units
K2 K
Other: Epogen, Procrit
IOM: 100-02, 15, 50
Coding Clinic: 2006, Q2, P5
❂ J0887 Injection, epoetin beta, 1 mcg, (for ESRD on dialysis)
N1 N
Other: Mircera
❂ J0888 Injection, epoetin beta, 1 mcg, (for non-ESRD use)
K2 K
Other: Mircera
✽ J0890 Injection, peginesatide, 0.1 mg (for ESRD on dialysis)
E1
Other: Omontys
▶ J0891 Injection, argatroban (accord), not therapeutically equivalent to
J0883, 1 mg (for non-ESRD use) K2 K

▶ J0892 Injection, argatroban (accord), not therapeutically equivalent to

J0884, 1 mg (for ESRD on dialysis) K2 K

▶ J0893 Injection, decitabine (sun pharma) not therapeutically equivalent to

J0894, 1 mg N

✽ J0894 Injection, decitabine, 1 mg K2 K

Indicated for treatment of myelodysplastic syndromes (MDS)

Other: Dacogen
❂ J0895 Injection, deferoxamine mesylate, 500 mg N1 N

Other: Desferal, Desferal mesylate

IOM: 100-02, 15, 50,
Cross Reference Q0087
❂ J0896 Injection, luspatercept-aamt, 0.25 mg K2 G

✽ J0897 Injection, denosumab, 1 mg K2 K

Other: Prolia, Xgeva

Coding Clinic: 2016, Q1, P5; 2012, Q1, P9
▶ J0898 Injection, argatroban (auromedics), not therapeutically equivalent to
J0883, 1 mg (for non-ESRD use) K2 K

▶ J0899 Injection, argatroban (auromedics), not therapeutically equivalent to

J0884, 1 mg (for ESRD on dialysis) K2 K

❂ J0945 Injection, brompheniramine maleate, per 10 mg N1 N

Other: Codimal-A, Cophene-B, Dehist, Histaject, Nasahist B, ND

Stat, Oraminic II, Sinusol-B
IOM: 100-02, 15, 50
❂ J1000 Injection, depo-estradiol cypionate, up to 5 mg N1 N

Other: DepGynogen, Depogen, Dura-Estrin, Estra-D, Estro-Cyp,

Estroject LA, Estronol-LA
IOM: 100-02, 15, 50
❂ J1020 Injection, methylprednisolone acetate, 20 mg N1 N

Other: DepMedalone, Depoject, Depo-Medrol, Depopred, D-Med

80, Duralone, Medralone, M-Prednisol, Rep-Pred
IOM: 100-02, 15, 50
Coding Clinic: 2019, Q3, P14; 2018, Q4, P5-6; 2005, Q3, P10
❂ J1030 Injection, methylprednisolone acetate, 40 mg N1 N

Other: DepMedalone, Depoject, Depo-Medrol, Depropred, D-Med

80, Duralone, Medralone, M-Prednisol, Rep-Pred
IOM: 100-02, 15, 50
Coding Clinic: 2019, Q3, P14; 2018, Q4, P6; 2005, Q3, P10
❂ J1040 Injection, methylprednisolone acetate, 80 mg N1 N

Other: DepMedalone, Depoject, Depo-Medrol, Depropred, D-Med

80, Duralone, Medralone, M-Prednisol, Rep-Pred
IOM: 100-02, 15, 50
Coding Clinic: 2018, Q4, P6
✽ J1050 Injection, medroxyprogesterone acetate, 1 mg N1 N
 Other: Depo-Provera Contraceptive
❂ J1071 Injection, testosterone cypionate, 1 mg N1 N

Other: Andro-Cyp, Andro/Fem, Andronaq-LA, Andronate, De-

Comberol, DepAndro, DepAndrogyn, Depotest, Depo-Testadiol,
Depo-Testosterone, Depotestrogen, Duratest, Duratestrin, Menoject
LA, Testa-C, Testadiate-Depo, Testaject-LA, Test-Estro Cypionates,
Testoject-LA
Coding Clinic: 2015, Q2, P7
❂ J1094 Injection, dexamethasone acetate, 1 mg N1 N

Other: Dalalone LA, Decadron LA, Decaject LA, Dexacen-LA-8,

Dexasone L.A., Dexone-LA, Solurex LA
IOM: 100-02, 15, 50
❂ J1095 Injection, dexamethasone 9%
✽ J1096 Dexamethasone, lacrimal ophthalmic insert, 0.1 mg K2 G

✽ J1097 Phenylephrine 10.16 mg/ml and ketorolac 2.88 mg/ml ophthalmic

irrigation solution, 1 ml K2 G

❂ J1100 Injection, dexamethasone sodium phosphate, 1 mg

Other: Dalalone, Decadron Phosphate, Decaject, Dexacen-4, N1 N

Dexone, Hexadrol Phosphate, Solurex

IOM: 100-02, 15, 50
❂ J1110 Injection, dihydroergotamine mesylate, per 1 mg K2 K

Other: D.H.E. 45
IOM: 100-02, 15, 50
❂ J1120 Injection, acetazolamide sodium, up to 500 mg N1 N

Other: Diamox
IOM: 100-02, 15, 50
✽ J1130 Injection, diclofenac sodium, 0.5 mg K2 K
Coding Clinic: 2017, Q1, P9
❂ J1160 Injection, digoxin, up to 0.5 mg N1 N

Other: Lanoxin
IOM: 100-02, 15, 50
❂ J1162 Injection, digoxin immune Fab (ovine), per vial K2 K

Other: DigiFab
IOM: 100-02, 15, 50
❂ J1165 Injection, phenytoin sodium, per 50 mg N1 N

Other: Dilantin
 IOM: 100-02, 15, 50
❂ J1170 Injection, hydromorphone, up to 4 mg N1 N

Other: Dilaudid
IOM: 100-02, 15, 50
❂ J1180 Injection, dyphylline, up to 500 mg E2

Other: Dilor, Lufyllin

IOM: 100-02, 15, 50
❂ J1190 Injection, dexrazoxane hydrochloride, per 250 mg K2 K

Other: Totect, Zinecard

IOM: 100-02, 15, 50
❂ J1200 Injection, diphenhydramine HCL, up to 50 mg N1 N

Other: Bena-D, Benadryl, Benahist, Ben-Allergin, Benoject,

Chlorothiazide sodium, Dihydrex, Diphenacen-50, Hyrexin-50,
Nordryl, Wehdryl
IOM: 100-02, 15, 50
❂ J1201 Injection, cetirizine hydrochloride, 0.5 mg K2 G

❂ J1205 Injection, chlorothiazide sodium, per 500 mg N1 N

Other: Diuril
IOM: 100-02, 15, 50
❂ J1212 Injection, DMSO, dimethyl sulfoxide, 50%, 50 ml
K2 K
Other: Rimso-50
IOM: 100-02, 15, 50; 100-03, 4, 230.12
❂ J1230 Injection, methadone HCL, up to 10 mg N1 N

Other: Dolophine HCl

MCM: 2049
IOM: 100-02, 15, 50
❂ J1240 Injection, dimenhydrinate, up to 50 mg N1 N

Other: Dinate, Dommanate, Dramamine, Dramanate, Dramilin,

Dramocen, Dramoject, Dymenate, Hydrate, Marmine, Wehamine
IOM: 100-02, 15, 50
❂ J1245 Injection, dipyridamole, per 10 mg N1 N

Other: Persantine
IOM: 100-04, 15, 50; 100-04, 12, 30.6
❂ J1250 Injection, dobutamine HCL, per 250 mg N1 N

Other: Dobutrex
 IOM: 100-02, 15, 50
❂ J1260 Injection, dolasetron mesylate, 10 mg N1 N

Other: Anzemet
IOM: 100-02, 15, 50
✽ J1265 Injection, dopamine HCL, 40 mg N1 N

✽ J1267 Injection, doripenem, 10 mg N1 N

Other: Donbax, Doribax

✽ J1270 Injection, doxercalciferol, 1 mcg N1 N

Other: Hectorol
✽ J1290 Injection, ecallantide, 1 mg K2 K

Other: Kalbitor
Coding Clinic: 2011, Q1, P7
✽ J1300 Injection, eculizumab, 10 mg K2 K

Other: Soliris
✽ J1301 Injection, edaravone, 1 mg G

Other: Radicava
▶ J1302 Injection, sutimlimab-jome, 10 mg K2 G

✽ J1303 Injection, ravulizumab-cwvz, 10 mg K2 G

✽ J1305 Injection, evinacumab-dgnb, 5mg K2 G

▶ J1306 Injection, inclisiran, 1 mg K2 G

❂ J1320 Injection, amitriptyline HCL, up to 20 mg N1 N

Other: Elavil, Enovil

IOM: 100-02, 15, 50
✽ J1322 Injection, elosulfase alfa, 1 mg K2 K

✽ J1324 Injection, enfuvirtide, 1 mg E2

❂ J1325 Injection, epoprostenol, 0.5 mg N1 N

Other: Flolan, Veletri

IOM: 100-02, 15, 50
❂ J1327 Injection, eptifibatide, 5 mg K2 K

Other: Integrilin
IOM: 100-02, 15, 50
❂ J1330 Injection, ergonovine maleate, up to 0.2 mg N1 N

Benefit limited to obstetrical diagnosis

IOM: 100-02, 15, 50
✽ J1335 Injection, ertapenem sodium, 500 mg N1 N

Other: Invanz
❂ J1364 Injection, erythromycin lactobionate, per 500 mg K2 K

IOM: 100-02, 15, 50

❂ J1380 Injection, estradiol valerate, up to 10 mg N1 N

Other: Delestrogen, Dioval, Duragen, Estra-L, Gynogen L.A.,

L.A.E. 20, Valergen
IOM: 100-02, 15, 50
Coding Clinic: 2011, Q1, P8
❂ J1410 Injection, estrogen conjugated, per 25 mg K2 K

Other: Premarin
IOM: 100-02, 15, 50
✽ J1426 Injection, casimersen, 10 mg K2 G

✽ J1427 Injection, viltolarsen, 10 mg K2 G

✽ J1428 Injection, eteplirsen, 10 mg K2 G

✽ J1429 Injection, golodirsen, 10 mg K2 G

❂ J1430 Injection, ethanolamine oleate, 100 mg K2 K

Other: Ethamolin
IOM: 100-02, 15, 50
❂ J1435 Injection, estrone, per 1 mg E2

Other: Estronol, Kestrone 5, Theelin Aqueous

IOM: 100-02, 15, 50
❂ J1436 Injection, etidronate disodium, per 300 mg E1

Other: Didronel
IOM: 100-02, 15, 50
❂ J1437 Injection, ferric derisomaltose, 10 mg K2 G

❂ J1438 Injection, etanercept, 25 mg (Code may be used for Medicare when

drug administered under the direct supervision of a physician, not
for use when drug is self-administered) K2 K

Other: Enbrel
IOM: 100-02, 15, 50
✽ J1439 Injection, ferric carboxymaltose, 1 mg K2 K

Other: Injectafer
❂ J1442 Injection, filgrastim (G-CSF), excludes biosimilars, 1 mcg
K2 K
 Other: Neupogen
✽ J1443 Injection, ferric pyrophosphate citrate solution (triferic), 0.1 mg of
iron N1 N

❂ J1444 Injection, ferric pyrophosphate citrate powder, 0.1 mg of iron N

❂ J1445 Injection, ferric pyrophosphate citrate solution (triferic avnu), 0.1

mg of iron K2 E2

❂ J1447 Injection, TBO-filgrastim, 1 mcg K2 K

Other: GRANIX
IOM: 100-02, 15, 50
❂ J1448 Injection, trilaciclib, 1mg K2 G

❂ J1450 Injection, fluconazole, 200 mg N1 N

Other: Diflucan
IOM: 100-02, 15, 50
❂ J1451 Injection, fomepizole, 15 mg K2 K

IOM: 100-02, 15, 50

❂ J1452 Injection, fomivirsen sodium, intraocular, 1.65 mg E2

IOM: 100-02, 15, 50

✽ J1453 Injection, fosaprepitant, 1 mg K2 K

Prevents chemotherapy-induced nausea and vomiting

Other: Emend
✽ J1454 Injection, fosnetupitant 235 mg and palonosetron 0.25 mg G

Other: Akynzeo and Aloxi

❂ J1455 Injection, foscarnet sodium, per 1000 mg K2 K

Other: Foscavir
IOM: 100-02, 15, 50
▶ J1456 Injection, fosaprepitant (teva), not therapeutically equivalent to
J1453, 1 mg N

✽ J1457 Injection, gallium nitrate, 1 mg E2

✽ J1458 Injection, galsulfase, 1 mg K2 K

Other: Naglazyme
✽ J1459 Injection, immune globulin (Privigen), intravenous, non-lyophilized
(e.g., liquid), 500 mg K2 K

❂ J1460 Injection, gamma globulin, intramuscular, 1 cc K2 K

Other: Gammar, GamaSTAN

IOM: 100-02, 15, 50
 Coding Clinic: 2011, Q1, P8
▶ J1551 Injection, immune globulin (cutaquig), 100 mg K2 K

✽ J1554 Injection, immune globulin (asceniv), 500 mg K2 G

✽ J1555 Injection, immune globulin (cuvitru), 100 mg K2 K

✽ J1556 Injection, immune globulin (Bivigam), 500 mg K2 K

✽ J1557 Injection, immune globulin, (gammaplex), intravenous, non-

lyophilized (e.g., liquid), 500 mg K2 K
Coding Clinic: 2012, Q1, P9
✽ J1558 Injection, immune globulin (xembify), 100 mg K2 G

✽ J1559 Injection, immune globulin (hizentra), 100 mg K2 K

Coding Clinic: 2011, Q1, P6
❂ J1560 Injection, gamma globulin, intramuscular, over 10 cc
K2 K
Other: Gammar, GamaSTAN
IOM: 100-02, 15, 50
❂ J1561 Injection, immune globulin, (Gamunex-C/Gammaked), non-
lyophilized (e.g., liquid), 500 mg K2 K

IOM: 100-02, 15, 50

Coding Clinic: 2012, Q1, P9
✽ J1562 Injection, immune globulin (Vivaglobin), 100 mg E2

❂ J1566 Injection, immune globulin, intravenous, lyophilized (e.g., powder),

not otherwise specified, 500 mg K2 K

Other: Carimune, Gammagard S/D, Polygam

IOM: 100-02, 15, 50
✽ J1568 Injection, immune globulin, (Octagam), intravenous, non-
lyophilized (e.g., liquid), 500 mg K2 K

❂ J1569 Injection, immune globulin, (Gammagard Liquid), non-lyophilized

(e.g., liquid), 500 mg K2 K

IOM: 100-02, 15, 50

❂ J1570 Injection, ganciclovir sodium, 500 mg N1 N

Other: Cytovene
IOM: 100-02, 15, 50
❂ J1571 Injection, hepatitis B immune globulin (HepaGam B),
intramuscular, 0.5 ml K2 K

IOM: 100-02, 15, 50

Coding Clinic: 2008, Q3, P7-8
❂ J1572 Injection, immune globulin, (flebogamma/flebogamma DIF)
 intravenous, non-lyophilized (e.g., liquid), 500 mg
K2 K
IOM: 100-02, 15, 50
✽ J1573 Injection, hepatitis B immune globulin (HepaGam B), intravenous,
0.5 ml K2 K
Coding Clinic: 2008, Q3, P8
▶ J1574 Injection, ganciclovir sodium (exela) not therapeutically equivalent
to J1570, 500 mg N

✽ J1575 Injection, immune globulin/hyaluronidase (HYQVIA), 100 mg

immunoglobulin K2 K

❂ J1580 Injection, Garamycin, gentamicin, up to 80 mg N1 N

Other: Gentamicin Sulfate, Jenamicin

IOM: 100-02, 15, 50
❂ J1595 Injection, glatiramer acetate, 20 mg K2 K

Other: Copaxone
IOM: 100-02, 15, 50
✽ J1599 Injection, immune globulin, intravenous, non-lyophilized (e.g.,
liquid), not otherwise specified, 500 mg N1 N
Coding Clinic: 2011, P1, Q6
❂ J1600 Injection, gold sodium thiomalate, up to 50 mg E2

Other: Myochrysine
IOM: 100-02, 15, 50
✽ J1602 Injection, golimumab, 1 mg for intravenous use K2 K

Other: Simponi Aria

❂ J1610 Injection, glucagon hydrochloride, per 1 mg K2 K

Other: GlucaGen, Glucagon Emergency

IOM: 100-02, 15, 50
▶ J1611 Injection, glucagon hydrochloride (fresenius kabi), not
therapeutically equivalent to J1610, per 1 mg K2 K

❂ J1620 Injection, gonadorelin hydrochloride, per 100 mcg E2

Other: Factrel
IOM: 100-02, 15, 50
❂ J1626 Injection, granisetron hydrochloride, 100 mcg N1 N

Other: Kytril
IOM: 100-02, 15, 50
✽ J1627 Injection, granisetron, extended-release, 0.1 mg K2 G
✽ J1628 Injection, guselkumab, 1 mg G

Other: Tremfya
❂ J1630 Injection, haloperidol, up to 5 mg N1 N

Other: Haldol, Haloperidol Lactate

IOM: 100-02, 15, 50
❂ J1631 Injection, haloperidol decanoate, per 50 mg N1 N

IOM: 100-02, 15, 50

❂ J1632 Injection, brexanolone, 1 mg K2 G

❂ J1640 Injection, hemin, 1 mg K2 K

Other: Panhematin
IOM: 100-02, 15, 50
❂ J1642 Injection, heparin sodium (heparin lock flush), per 10 units
N1 N
Other: Hep-Lock U/P, Vasceze
IOM: 100-02, 15, 50
▶ J1643 Injection, heparin sodium (pfizer), not therapeutically equivalent to
J1644, per 1000 units N

❂ J1644 Injection, heparin sodium, per 1000 units N1 N

Other: Heparin Sodium (Porcine), Liquaemin Sodium

IOM: 100-02, 15, 50
❂ J1645 Injection, dalteparin sodium, per 2500 IU N1 N

Other: Fragmin
IOM: 100-02, 15, 50
✽ J1650 Injection, enoxaparin sodium, 10 mg N1 N

Other: Lovenox
❂ J1652 Injection, fondaparinux sodium, 0.5 mg N1 N

Other: Arixtra
IOM: 100-02, 15, 50
✽ J1655 Injection, tinzaparin sodium, 1000 IU N1 N

Other: Innohep
❂ J1670 Injection, tetanus immune globulin, human, up to 250 units
K2 K
Indicated for transient protection against tetanus post-exposure to
tetanus (Z23).
Other: Hyper-Tet
 IOM: 100-02, 15, 50
❂ J1675 Injection, histrelin acetate, 10 mcg B

IOM: 100-02, 15, 50

❂ J1700 Injection, hydrocortisone acetate, up to 25 mg N1 N

Other: Hydrocortone Acetate

IOM: 100-02, 15, 50
❂ J1710 Injection, hydrocortisone sodium phosphate, up to 50 mg
N1 N
Other: A-hydroCort, Hydrocortone phosphate, Solu-Cortef
IOM: 100-02, 15, 50
❂ J1720 Injection, hydrocortisone sodium succinate, up to 100 mg
N1 N
Other: A-HydroCort, Solu-Cortef
IOM: 100-02, 15, 50
✽ J1726 Injection, hydroxyprogesterone caproate (makena), 10 mg K2 K

✽ J1729 Injection, hydroxyprogesterone caproate, not otherwise specified, 10

mg N1 N

❂ J1730 Injection, diazoxide, up to 300 mg E2

Other: Hyperstat
IOM: 100-02, 15, 50
✽ J1738 Injection, meloxicam, 1 mg K2 G

✽ J1740 Injection, ibandronate sodium, 1 mg K2 K

Other: Boniva
✽ J1741 Injection, ibuprofen, 100 mg N1 N

Other: Caldolor
❂ J1742 Injection, ibutilide fumarate, 1 mg K2 K

Other: Corvert
IOM: 100-02, 15, 50
✽ J1743 Injection, idursulfase, 1 mg K2 K

Other: Elaprase
✽ J1744 Injection, icatibant, 1 mg K2 K

Other: Firazyr
❂ J1745 Injection, infliximab, excludes biosimilar, 10 mg K2 K

Report total number of 10 mg increments administered For

biosimilar, Inflectra, report Q5102
Other: Remicade
 IOM: 100-02, 15, 50
✽ J1746 Injection, ibalizumab-uiyk, 10 mg K

Other: Trogarzo
❂ J1750 Injection, iron dextran, 50 mg K2 K

Other: Dexferrum, Imferon, Infed

IOM: 100-02, 15, 50
✽ J1756 Injection, iron sucrose, 1 mg N1 N

Other: Venofer
❂ J1786 Injection, imiglucerase, 10 units K2 K

Other: Cerezyme
IOM: 100-02, 15, 50
Coding Clinic: 2011, Q1, P8
❂ J1790 Injection, droperidol, up to 5 mg N1 N

Other: Inapsine
IOM: 100-02, 15, 50
❂ J1800 Injection, propranolol HCL, up to 1 mg N1 N

Other: Inderal
IOM: 100-02, 15, 50
❂ J1810 Injection, droperidol and fentanyl citrate, up to 2 ml ampule
E1
Other: Innovar
IOM: 100-02, 15, 50
❂ J1815 Injection, insulin, per 5 units N1 N

Other: Humalog, Humulin, Lantus, Novolin, Novolog

IOM: 100-02, 15, 50; 100-03, 4, 280.14
✽ J1817 Insulin for administration through DME (i.e., insulin pump) per 50
units N1 N

Other: Apidra Solostar, Insulin Lispro, Humalog, Humulin, Novolin,

Novolog
✽ J1823 Injection, inebilizumab-cdon, 1 mg K2 G

✽ J1826 Injection, interferon beta-1a, 30 mcg K2 K

Other: Avonex
Coding Clinic: 2011, Q2, P9; Q1, P8
❂ J1830 Injection, interferon beta-1b, 0.25 mg (Code may be used for
Medicare when drug administered under the direct supervision of a
 physician, not for use when drug is self-administered)
K2 K
Other: Betaseron
IOM: 100-02, 15, 50
✽ J1833 Injection, isavuconazonium, 1 mg K2 K

✽ J1835 Injection, itraconazole, 50 mg E2

Other: Sporanox
❂ J1840 Injection, kanamycin sulfate, up to 500 mg N1 N

Other: Kantrex, Klebcil

IOM: 100-02, 15, 50
❂ J1850 Injection, kanamycin sulfate, up to 75 mg N1 N

Other: Kantrex, Klebcil

IOM: 100-02, 15, 50
Coding Clinic: 2013: Q2, P3
❂ J1885 Injection, ketorolac tromethamine, per 15 mg N1 N

Other: Toradol
IOM: 100-02, 15, 50
❂ J1890 Injection, cephalothin sodium, up to 1 gram N1 N

Other: Keflin
IOM: 100-02, 15, 50
✽ J1930 Injection, lanreotide, 1 mg K2 K

Treats acromegaly and symptoms caused by neuroendocrine tumors

Other: Somatuline Depot
✽ J1931 Injection, laronidase, 0.1 mg K2 K

Other: Aldurazyme
▶ J1932 Injection, lanreotide, (cipla), 1 mg K2 K

❂ J1940 Injection, furosemide, up to 20 mg N1 N

Other: Furomide M.D., Lasix

MCM: 2049
IOM: 100-02, 15, 50
✽ J1943 Injection, aripiprazole lauroxil, (aristada initio), 1 mg K2 G

✽ J1944 Injection, aripiprazole lauroxil, (aristada), 1 mg K2 K

❂ J1945 Injection, lepirudin, 50 mg E2

 IOM: 100-02, 15, 50
❂ J1950 Injection, leuprolide acetate (for depot suspension), per 3.75 mg
K2 K

Other: Lupron, Lupron Depot, Lupron Depot-Ped

IOM: 100-02, 15, 50
Coding Clinic: 2019, Q2, P11-12
✽ J1951 Injection, leuprolide acetate for depot suspension (fensolvi), 0.25
mg K2 K

✽ J1952 Leuprolide injectable, camcevi, 1 mg K5 E2

✽ J1953 Injection, levetiracetam, 10 mg N1 N

Other: Keppra
❂ J1955 Injection, levocarnitine, per 1 gm B

Other: Carnitor
IOM: 100-02, 15, 50
❂ J1956 Injection, levofloxacin, 250 mg N1 N

Other: Levaquin
IOM: 100-02, 15, 50
❂ J1960 Injection, levorphanol tartrate, up to 2 mg N1 N

Other: Levo-Dromoran
MCM: 2049
IOM: 100-02, 15, 50
❂ J1980 Injection, hyoscyamine sulfate, up to 0.25 mg N1 N

Other: Levsin
IOM: 100-02, 15, 50
❂ J1990 Injection, chlordiazepoxide HCL, up to 100 mg N1 N

Other: Librium
IOM: 100-02, 15, 50
❂ J2001 Injection, lidocaine HCL for intravenous infusion, 10 mg
N1 N
Other: Caine-1, Caine-2, Dilocaine, L-Caine, Lidocaine in
D5W, Lidoject, Nervocaine, Nulicaine, Xylocaine
IOM: 100-02, 15, 50
❂ J2010 Injection, lincomycin HCL, up to 300 mg N1 N

Other: Lincocin
IOM: 100-02, 15, 50
✽ J2020 Injection, linezolid, 200 mg N1 N
 Other: Zyvox
▶ J2021 Injection, linezolid (hospira) not therapeutically equivalent to J2020,
200 mg N

❂ J2060 Injection, lorazepam, 2 mg N1 N

Other: Ativan
IOM: 100-02, 15, 50
✽ J2062 Loxapine for inhalation, 1 mg K

Other: Adasuve
❂ J2150 Injection, mannitol, 25% in 50 ml N1 N

Other: Aridol
MCM: 2049
IOM: 100-02, 15, 50
✽ J2170 Injection, mecasermin, 1 mg N1 N

Other: Increlex
❂ J2175 Injection, meperidine hydrochloride, per 100 mg N1 N

Other: Demerol
IOM: 100-02, 15, 50
❂ J2180 Injection, meperidine and promethazine HCL, up to 50 mg
N1 N
Other: Mepergan
IOM: 100-02, 15, 50
✽ J2182 Injection, mepolizumab, 1 mg K2 G

▶ J2184 Injection, meropenem (b. braun) not therapeutically equivalent to

J2185, 100 mg N

✽ J2185 Injection, meropenem, 100 mg N1 N

Other: Merrem
✽ J2186 Inj., meropenem, vaborbactam G

Other: Vabomere
Medicare Statute 1833(t)
❂ J2210 Injection, methylergonovine maleate, up to 0.2 mg
N1 N
Benefit limited to obstetrical diagnoses for prevention and
control of postpartum hemorrhage
Other: Methergine
IOM: 100-02, 15, 50
✽ J2212 Injection, methylnaltrexone, 0.1 mg N1 N
 Other: Relistor
▶ J2247 Injection, micafungin sodium (par pharm) not thereapeutically
equivalent to J2248, 1 mg N

✽ J2248 Injection, micafungin sodium, 1 mg N1 N

Other: Mycamine
❂ J2250 Injection, midazolam hydrochloride, per 1 mg N1 N

Other: Versed
IOM: 100-02, 15, 50
▶ J2251 Injection, midazolam hydrochloride (wg critical care) not
therapeutically equivalent to J2250, per 1 mg N

❂ J2260 Injection, milrinone lactate, 5 mg N1 N

Other: Primacor
IOM: 100-02, 15, 50
✽ J2265 Injection, minocycline hydrochloride, 1 mg K2 K

Other: Minocine
❂ J2270 Injection, morphine sulfate, up to 10 mg N1 N

Other: Astramorph PF, Duramorph

IOM: 100-02, 15, 50
Coding Clinic: 2013, Q2, P4
▶ J2272 Injection, morphine sulfate (fresenius kabi) not therapeutically
equivalent to J2270, up to 10 mg N

❂ J2274 Injection, morphine sulfate, preservative-free for epidural or

intrathecal use, 10 mg N1 N

Other: Duramorph, Infumorph

IOM: 100-03, 4, 280.1; 100-02, 15, 50
❂ J2278 Injection, ziconotide, 1 mcg K2 K

Other: Prialt
✽ J2280 Injection, moxifloxacin, 100 mg N1 N

Other: Avelox
▶ J2281 Injection, moxifloxacin (fresenius kabi) not therapeutically
equivalent to J2280, 100 mg N

❂ J2300 Injection, nalbuphine hydrochloride, per 10 mg N1 N

Other: Nubain
IOM: 100-02, 15, 50
❂ J2310 Injection, naloxone hydrochloride, per 1 mg N1 N

Other: Narcan
IOM: 100-02, 15, 50
▶ J2311 Injection, naloxone hydrochloride (zimhi), 1 mg N

✽ J2315 Injection, naltrexone, depot form, 1 mg K2 K

Other: Vivitrol
❂ J2320 Injection, nandrolone decanoate, up to 50 mg K2 K

Other: Anabolin LA 100, Androlone, Deca-Durabolin, Decolone,

Hybolin Decanoate, Nandrobolic LA, Neo-Durabolic
IOM: 100-02, 15, 50
Coding Clinic: 2011, Q1, P8
✽ J2323 Injection, natalizumab, 1 mg K2 K

Other: Tysabri
❂ J2325 Injection, nesiritide, 0.1 mg K2 K

Other: Natrecor
IOM: 100-02, 15, 50
✽ J2326 Injection, nusinersen, 0.1 mg K2 G
Coding Clinic: 2021, Q1, P11; 2020, Q1, P11
▶ J2327 Injection, risankizumab-rzaa, intravenous, 1 mg K2 G

✽ J2350 Injection, ocrelizumab, 1 mg K2 G

✽ J2353 Injection, octreotide, depot form for intramuscular injection, 1 mg

K2 K

Other: Sandostatin LAR Depot

✽ J2354 Injection, octreotide, non-depot form for subcutaneous or
intravenous injection, 25 mcg N1 N

Other: Sandostatin LAR Depot

❂ J2355 Injection, oprelvekin, 5 mg K2 K

Other: Neumega
IOM: 100-02, 15, 50
▶ J2356 Injection, tezepelumab-ekko, 1 mg K2 K

✽ J2357 Injection, omalizumab, 5 mg K2 K

Other: Xolair
✽ J2358 Injection, olanzapine, long-acting, 1 mg N1 N

Other: Zyprexa Relprevv

Coding Clinic: 2011, Q1, P6
❂ J2360 Injection, orphenadrine citrate, up to 60 mg N1 N

Other: Antiflex, Banflex, Flexoject, Flexon, K-Flex, Myolin,

Neocyten, Norflex, O-Flex, Orphenate
IOM: 100-02, 15, 50
❂ J2370 Injection, phenylephrine HCL, up to 1 ml N1 N

Other: Neo-Synephrine
IOM: 100-02, 15, 50
J2400 Injection, chloroprocaine hydrochloride, per 30 ml ✖
Other: Nesacaine, Nesacaine-MPF
IOM: 100-02, 15, 50
▶ J2401 Injection, chloroprocaine hydrochloride, per 1 mg N

▶ J2402 Injection, chloroprocaine hydrochloride (clorotekal), per 1 mg N

J2405 Injection, ondansetron hydrochloride, per 1 mg ✖

Other: Zofran
IOM: 100-02, 15, 50
❂ J2406 Injection, oritavancin (kimyrsa), 10 mg K2 G

❂ J2407 Injection, oritavancin (orbactiv), 10 mg K2 K

Other: Orbactiv
IOM: 100-02, 15, 50
❂ J2410 Injection, oxymorphone HCL, up to 1 mg N1 N

Other: Numorphan, Opana

IOM: 100-02, 15, 50
✽ J2425 Injection, palifermin, 50 mcg K2 K

Other: Kepivance
✽ J2426 Injection, paliperidone palmitate extended release, 1 mg
K2 K
Other: Invega Sustenna
Coding Clinic: 2011, Q1, P7
❂ J2430 Injection, pamidronate disodium, per 30 mg N1 N

Other: Aredia
IOM: 100-02, 15, 50
❂ J2440 Injection, papaverine HCL, up to 60 mg N1 N

IOM: 100-02, 15, 50

❂ J2460 Injection, oxytetracycline HCL, up to 50 mg E2

Other: Terramycin IM
 IOM: 100-02, 15, 50
✽ J2469 Injection, palonosetron HCL, 25 mcg K2 K

Example: 0.25 mgm dose = 10 units Example of use is acute,

delayed, nausea and vomiting due to chemotherapy
Other: Aloxi
❂ J2501 Injection, paricalcitol, 1 mcg N1 N

Other: Zemplar
IOM: 100-02, 15, 50
✽ J2502 Injection, pasireotide long acting, 1 mg K2 K

Other: Signifor LAR

✽ J2503 Injection, pegaptanib sodium, 0.3 mg K2 K

Other: Macugen
❂ J2504 Injection, pegademase bovine, 25 IU K2 K

Other: Adagen
IOM: 100-02, 15, 50
✽ J2506 Injection, pegfilgrastim, excludes biosimilar, 0.5 mg K2 K

✽ J2507 Injection, pegloticase, 1 mg K2 K

Other: Krystexxa
Coding Clinic: 2012, Q1, P9
❂ J2510 Injection, penicillin G procaine, aqueous, up to 600,000 units
N1 N

Other: Crysticillin, Duracillin AS, Pfizerpen AS, Wycillin

IOM: 100-02, 15, 50
❂ J2513 Injection, pentastarch, 10% solution, 100 ml E2

IOM: 100-02, 15, 50

❂ J2515 Injection, pentobarbital sodium, per 50 mg K2 K

Other: Nembutal sodium solution

IOM: 100-02, 15, 50
❂ J2540 Injection, penicillin G potassium, up to 600,000 units
N1 N
Other: Pfizerpen-G
IOM: 100-02, 15, 50
❂ J2543 Injection, piperacillin sodium/tazobactam sodium, 1 gram/0.125
grams (1.125 grams) N1 N

Other: Zosyn
IOM: 100-02, 15, 50
❂ J2545 Pentamidine isethionate, inhalation solution, FDA-approved final
product, non-compounded, administered through DME, unit dose
form, per 300 mg B

Other: Nebupent
✽ J2547 Injection, peramivir, 1 mg K2 K

❂ J2550 Injection, promethazine HCL, up to 50 mg N1 N

Administration of phenergan suppository considered part of E/M

encounter
Other: Anergan, Phenazine, Phenergan, Prorex, Prothazine, V-Gan
IOM: 100-02, 15, 50
❂ J2560 Injection, phenobarbital sodium, up to 120 mg N1 N

Other: Luminal Sodium

IOM: 100-02, 15, 50
✽ J2562 Injection, plerixafor, 1 mg K2 K

FDA approved for non-Hodgkin lymphoma and multiple myeloma

in 2008.
Other: Mozobil
❂ J2590 Injection, oxytocin, up to 10 units N1 N

Other: Pitocin, Syntocinon

IOM: 100-02, 15, 50
❂ J2597 Injection, desmopressin acetate, per 1 mcg K2 K

Other: DDAVP
IOM: 100-02, 15, 50
❂ J2650 Injection, prednisolone acetate, up to 1 ml N1 N

Other: Key-Pred, Predalone, Predcor, Predicort, Predoject

IOM: 100-02, 15, 50
❂ J2670 Injection, tolazoline HCL, up to 25 mg N1 N

Other: Priscoline HCl

IOM: 100-02, 15, 50
❂ J2675 Injection, progesterone, per 50 mg N1 N

Other: Gesterol 50, Progestaject

IOM: 100-02, 15, 50
❂ J2680 Injection, fluphenazine decanoate, up to 25 mg N1 N

Other: Prolixin Decanoate

MCM: 2049
 IOM: 100-02, 15, 50
❂ J2690 Injection, procainamide HCL, up to 1 gm ♀ N1 N

Benefit limited to obstetrical diagnoses

Other: Pronestyl, Prostaphlin
IOM: 100-02, 15, 50
❂ J2700 Injection, oxacillin sodium, up to 250 mg N1 N

Other: Bactocill
IOM: 100-02, 15, 50
✽ J2704 Injection, propofol, 10 mg N1 N

Other: Diprivan
❂ J2710 Injection, neostigmine methylsulfate, up to 0.5 mg
N1 N
Other: Prostigmin
IOM: 100-02, 15, 50
❂ J2720 Injection, protamine sulfate, per 10 mg N1 N

IOM: 100-02, 15, 50

✽ J2724 Injection, protein C concentrate, intravenous, human, 10 IU
K2 K
Other: Ceprotin
❂ J2725 Injection, protirelin, per 250 mcg E2

Other: Relefact TRH, Thypinone

IOM: 100-02, 15, 50
❂ J2730 Injection, pralidoxime chloride, up to 1 gm N1 N

Other: Protopam Chloride

IOM: 100-02, 15, 50
❂ J2760 Injection, phentolamine mesylate, up to 5 mg K2 K

Other: Regitine
IOM: 100-02, 15, 50
❂ J2765 Injection, metoclopramide HCL, up to 10 mg N1 N

Other: Reglan
IOM: 100-02, 15, 50
❂ J2770 Injection, quinupristin/dalfopristin, 500 mg (150/350)
K2 K
Other: Synercid
IOM: 100-02, 15, 50
▶ J2777 Injection, faricimab-svoa, 0.1 mg K2 K
✽ J2778 Injection, ranibizumab, 0.1 mg K2 K

May be reported for exudative senile macular degeneration (wet

AMD) with 67028 (RT or LT)
Other: Lucentis
▶ J2779 Injection, ranibizumab, via intravitreal implant (susvimo), 0.1 mg
K2 K
❂ J2780 Injection, ranitidine hydrochloride, 25 mg N1 N

Other: Zantac
IOM: 100-02, 15, 50
✽ J2783 Injection, rasburicase, 0.5 mg K2 K

Other: Elitek
✽ J2785 Injection, regadenoson, 0.1 mg N1 N

One billing unit equal to 0.1 mg of regadenoson

Other: Lexiscan
✽ J2786 Injection, reslizumab, 1 mg K2 G
Coding Clinic: 2016, Q4, P9
✽ J2787 Riboflavin 5’-phosphate, ophthalmic solution, up to 3 mL
Other: Photrexa Viscous
❂ J2788 Injection, Rho D immune globulin, human, minidose, 50 mcg (250
IU) N1 N

Other: HypRho-D, MicRhoGAM, Rhesonativ, RhoGam

IOM: 100-02, 15, 50
❂ J2790 Injection, Rho D immune globulin, human, full dose, 300 mcg
(1500 IU) N1 N

Administered to pregnant female to prevent hemolistic disease of

newborn. Report 90384 to private payer
Other: Gamulin Rh, Hyperrho S/D, HypRho-D, Rhesonativ,
RhoGAM
IOM: 100-02, 15, 50
❂ J2791 Injection, Rho(D) immune globulin (human), (Rhophylac),
intramuscular or intravenous, 100 IU N1 N

Agent must be billed per 100 IU in both physician office and

hospital outpatient settings
Other: HypRho-D
IOM: 100-02, 15, 50
❂ J2792 Injection, Rho D immune globulin intravenous, human, solvent
 detergent, 100 IU K2 K

Other: Gamulin Rh, Hyperrho S/D, WinRHo-SDF

IOM: 100-02, 15, 50
❂ J2793 Injection, rilonacept, 1 mg K2 K

Other: Arcalyst
IOM: 100-02, 15, 50
✽ J2794 Injection, risperidone (risperdal consta), 0.5 mg K2 K

Other: Risperdal Costa

✽ J2795 Injection, ropivacaine hydrochloride, 1 mg N1 N

Other: Naropin
✽ J2796 Injection, romiplostim, 10 mcg K2 K

Stimulates bone marrow megakarocytes to produce platelets (i.e.,

ITP)
Other: Nplate
❂ J2797 Injection, rolapitant, 0.5 mg G

Other: Varubi
✽ J2798 Injection, risperidone, (perseris), 0.5 mg K2 G

❂ J2800 Injection, methocarbamol, up to 10 ml N1 N

Other: Robaxin
IOM: 100-02, 15, 50
✽ J2805 Injection, sincalide, 5 mcg N1 N

Other: Kinevac
❂ J2810 Injection, theophylline, per 40 mg N1 N

IOM: 100-02, 15, 50

❂ J2820 Injection, sargramostim (GM-CSF), 50 mcg K2 K

Other: Leukine, Prokine

IOM: 100-02, 15, 50
✽ J2840 Injection, sebelipase alfa, 1 mg K2 G

❂ J2850 Injection, secretin, synthetic, human, 1 mcg K2 K

Other: Chirhostim
IOM: 100-02, 15, 50
✽ J2860 Injection, siltuximab, 10 mg K2 K

❂ J2910 Injection, aurothioglucose, up to 50 mg E2

 Other: Solganal
IOM: 100-02, 15, 50
❂ J2916 Injection, sodium ferric gluconate complex in sucrose injection,
12.5 mg N1 N

Other: Ferrlecit, Nulecit

IOM: 100-02, 15, 50
❂ J2920 Injection, methylprednisolone sodium succinate, up to 40 mg
N1 N

Other: A-MethaPred, Solu-Medrol

IOM: 100-02, 15, 50
❂ J2930 Injection, methylprednisolone sodium succinate, up to 125 mg
N1 N

Other: A-MethaPred, Solu-Medrol

IOM: 100-02, 15, 50
❂ J2940 Injection, somatrem, 1 mg E2

IOM: 100-02, 15, 50,

Medicare Statute 1861s2b
❂ J2941 Injection, somatropin, 1 mg K2 K

Other: Genotropin, Humatrope, Nutropin, Omnitrope, Saizen,

Serostim, Zorbtive
IOM: 100-02, 15, 50,
Medicare Statute 1861s2b
❂ J2950 Injection, promazine HCL, up to 25 mg N1 N

Other: Prozine-50, Sparine

IOM: 100-02, 15, 50
❂ J2993 Injection, reteplase, 18.1 mg K2 K

Other: Retavase
IOM: 100-02, 15, 50
❂ J2995 Injection, streptokinase, per 250,000 IU N1 N

Bill 1 unit for each 250,000 IU

Other: Kabikinase, Streptase
IOM: 100-02, 15, 50
❂ J2997 Injection, alteplase recombinant, 1 mg K2 K

Thrombolytic agent, treatment of occluded catheters. Bill units of 1

mg administered.
 Other: Activase, Cathflo Activase
IOM: 100-02, 15, 50
Coding Clinic: 2014, Q1, P4
▶ J2998 Injection, plasminogen, human-tvmh, 1 mg K2 K

❂ J3000 Injection, streptomycin, up to 1 gm N1 N

IOM: 100-02, 15, 50

❂ J3010 Injection, fentanyl citrate, 0.1 mg N1 N

Other: Sublimaze
IOM: 100-02, 15, 50
❂ J3030 Injection, sumatriptan succinate, 6 mg (Code may be used for
Medicare when drug administered under the direct supervision of a
physician, not for use when drug is self-administered)
N1 N
Other: Imitrex, Sumarel Dosepro
IOM: 100-02, 15, 150
✽ J3031 Injection, fremanezumab-vfrm, 1 mg (Code may be used for
Medicare when drug administered under the direct supervision of a
physician, not for use when drug is self-administered) K2 G

✽ J3032 Injection, eptinezumab-jjmr, 1 mg K2 G

✽ J3060 Injection, taliglucerase alfa, 10 units K2 K

Other: Elelyso
❂ J3070 Injection, pentazocine, 30 mg K2 K

Other: Talwin
IOM: 100-02, 15, 50
✽ J3090 Injection, tedizolid phosphate, 1 mg K2 K

Other: Sivextro
✽ J3095 Injection, televancin, 10 mg K2 K

Prescribed for the treatment of adults with complicated skin and

skin structure infections (cSSSI) of the following Gram-positive
microorganisms: Staphylococcus aureus; Streptococcus pyogenes,
Streptococcus agalactiae, Streptococcus anginosusgroup. Separately
payable under the ASC payment system.
Other: Vibativ
Coding Clinic: 2011, Q1, P7
✽ J3101 Injection, tenecteplase, 1 mg K2 K

Other: TNKase
❂ J3105 Injection, terbutaline sulfate, up to 1 mg N1 N
 Other: Brethine
IOM: 100-02, 15, 50
❂ J3110 Injection, teriparatide, 10 mcg B

✽ J3111 Injection, romosozumab-aqqg, 1 mg K2 G

❂ J3121 Injection, testosterone enanthate, 1 mg N1 N

Other: Andrest 90-4, Andro L.A. 200, Andro-Estro 90-4, Androgyn

L.A, Andropository 100, Andryl 200, Deladumone, Deladumone OB,
Delatest, Delatestadiol, Delatestryl, Ditate-DS, Dua-Gen L.A.,
Duoval P.A., Durathate-200, Estra-Testrin, Everone, TEEV,
Testadiate, Testone LA, Testradiol 90/4, Testrin PA, Valertest
❂ J3145 Injection, testosterone undecanoate, 1 mg K2 K

❂ J3230 Injection, chlorpromazine HCL, up to 50 mg N1 N

Other: Ormazine, Thorazine

IOM: 100-02, 15, 50
❂ J3240 Injection, thyrotropin alfa, 0.9 mg provided in 1.1 mg vial
K2 K
Other: Thyrogen
IOM: 100-02, 15, 50
✽ J3241 Injection, teprotumumab-trbw, 10 mg K2 G

✽ J3243 Injection, tigecycline, 1 mg K2 K

▶ J3244 Injection, tigecycline (accord) not therapeutically equivalent to

J3243, 1 mg N

✽ J3245 Injection, tildrakizumab, 1 mg E2

Other: Ilumya
✽ J3246 Injection, tirofiban HCL, 0.25 mg K2 K

Other: Aggrastat
❂ J3250 Injection, trimethobenzamide HCL, up to 200 mg N1 N

Other: Arrestin, Ticon, Tigan, Tiject 20

IOM: 100-02, 15, 50
❂ J3260 Injection, tobramycin sulfate, up to 80 mg N1 N

Other: Nebcin
IOM: 100-02, 15, 50
✽ J3262 Injection, tocilizumab, 1 mg K2 K

Indicated for the treatment of adult patients with moderately to

severely active rheumatoid arthritis (RA) who have had an
 inadequate response to one or more tumor necrosis factor (TNF)
antagonist therapies.
Other: Actemra
Coding Clinic: 2011, Q1, P7
❂ J3265 Injection, torsemide, 10 mg/ml N1 N

Other: Demadex
IOM: 100-02, 15, 50
❂ J3280 Injection, thiethylperazine maleate, up to 10 mg E2

Other: Norzine, Torecan

IOM: 100-02, 15, 50
✽ J3285 Injection, treprostinil, 1 mg K2 K

Other: Remodulin
▶ J3299 Injection, triamcinolone acetonide (xipere), 1 mg K

❂ J3300 Injection, triamcinolone acetonide, preservative free, 1 mg

K2 K
Other: Cenacort A-40, Kenaject-40, Kenalog, Triam-A, Triesence,
Tri-Kort, Trilog
❂ J3301 Injection, triamcinolone acetonide, not otherwise specified, 10 mg
N1 N

Other: Cenacort A-40, Kenaject-40, Kenalog, Triam A, Triesence,

Tri-Kort, Trilog
IOM: 100-02, 15, 50
Coding Clinic: 2018, Q4, P7; 2013, Q2, P4
❂ J3302 Injection, triamcinolone diacetate, per 5 mg N1 N

Other: Amcort, Aristocort, Cenacort Forte, Trilone

IOM: 100-02, 15, 50
❂ J3303 Injection, triamcinolone hexacetonide, per 5 mg N1 N

Other: Aristospan
IOM: 100-02, 15, 50
❂ J3304 Injection, triamcinolone acetonide, preservative-free, extended-
release, microsphere formulation, 1 mg G

Other: Zilretta
❂ J3305 Injection, trimetrexate glucuronate, per 25 mg E2

Other: NeuTrexin
IOM: 100-02, 15, 50
❂ J3310 Injection, perphenazine, up to 5 mg N1 N
 Other: Trilafon
IOM: 100-02, 15, 50
❂ J3315 Injection, triptorelin pamoate, 3.75 mg K2 K

Other: Trelstar
IOM: 100-02, 15, 50
❂ J3316 Injection, triptorelin, extended-release, 3.75 mg G

Other: Trelstar, Trelstar Depot, Trelstar LA

❂ J3320 Injection, spectinomycin dihydrochloride, up to 2 gm E2

Other: Trobicin
IOM: 100-02, 15, 50
❂ J3350 Injection, urea, up to 40 gm N1 N

Other: Ureaphil
IOM: 100-02, 15, 50
❂ J3355 Injection, urofollitropin, 75 IU E2

Other: Bravelle, Metrodin

IOM: 100-02, 15, 50
✽ J3357 Ustekinumab, for subcutaneous injection, 1 mg K2 K

Other: Stelara
Coding Clinic: 2017, Q1, P3; 2016, Q4, P10; 2011, Q1, P7
✽ J3358 Ustekinumab, for intravenous injection, 1 mg K2 G

Cross Reference Q9989

❂ J3360 Injection, diazepam, up to 5 mg N1 N

Other: Valium, Zetran

IOM: 100-02, 15, 50
Coding Clinic: 2007, Q2, P6-7
❂ J3364 Injection, urokinase, 5000 IU vial N1 N

Other: Abbokinase
IOM: 100-02, 15, 50
❂ J3365 Injection, IV, urokinase, 250,000 IU vial E2

Other: Abbokinase
IOM: 100-02, 15, 50,
Cross Reference Q0089
❂ J3370 Injection, vancomycin HCL, 500 mg N1 N

Other: Vancocin, Vancoled

IOM: 100-02, 15, 50; 100-03, 4, 280.14
▶ J3371 Injection, vancomycin hcl (mylan) not therapeutically equivalent to
J3370, 500 mg N

▶ J3372 Injection, vancomycin hcl (xellia) not therapeutically equivalent to

J3370, 500 mg N

❂ J3380 Injection, vedolizumab, 1 mg K2 K

Other: Entyvio
✽ J3385 Injection, velaglucerase alfa, 100 units K2 K

Enzyme replacement therapy in Gaucher Disease that results from a

specific enzyme deficiency in the body, caused by a genetic
mutation received from both parents. Type 1 is the most prevalent
Ashkenazi Jewish genetic disease, occurring in one in every 1,000.
Other: VPRIV
Coding Clinic: 2011, Q1, P7
❂ J3396 Injection, verteporfin, 0.1 mg K2 K

Other: Visudyne
IOM: 100-03, 1, 80.2; 100-03, 1, 80.3
✽ J3397 Injection, vestronidase alfa-vjbk, 1 mg K

Other: Mepsevii
✽ J3398 Injection, voretigene neparvovec-rzyl, 1 billion vector genomes
G
Other: Luxturna
✽ J3399 Injection, onasemnogene abeparvovecxioi, per treatment, up to
5x10^15 vector genomes K

❂ J3400 Injection, triflupromazine HCL, up to 20 mg E2

Other: Vesprin
IOM: 100-02, 15, 50
❂ J3410 Injection, hydroxyzine HCL, up to 25 mg N1 N

Other: Hyzine-50, Vistaject 25, Vistaril

IOM: 100-02, 15, 50
✽ J3411 Injection, thiamine HCL, 100 mg N1 N

✽ J3415 Injection, pyridoxine HCL, 100 mg N1 N

❂ J3420 Injection, vitamin B-12 cyanocobalamin, up to 1000 mcg

Medicare carriers may have local coverage decisions
N1 N
regarding vitamin B12 injections that provide reimbursement
only for patients with certain types of anemia and other conditions.
 Other: Berubigen, Betalin 12, Cobex, Redisol, Rubramin PC,
Sytobex
IOM: 100-02, 15, 50; 100-03, 2, 150.6
❂ J3430 Injection, phytonadione (vitamin K), per 1 mg N1 N

Other: AquaMephyton, Konakion, Menadione, Synkavite, Vitamin

K1
IOM: 100-02, 15, 50
❂ J3465 Injection, voriconazole, 10 mg K2 K

Other: VFEND
IOM: 100-02, 15, 50
❂ J3470 Injection, hyaluronidase, up to 150 units N1 N

Other: Amphadase, Wydase

IOM: 100-02, 15, 50
❂ J3471 Injection, hyaluronidase, ovine, preservative free, per 1 USP unit
(up to 999 USP units) N1 N

Other: Vitrase
❂ J3472 Injection, hyaluronidase, ovine, preservative free, per 1000 USP
units N1 N

❂ J3473 Injection, hyaluronidase, recombinant, 1 USP unit N1 N

Other: Hylenex
IOM: 100-02, 15, 50
❂ J3475 Injection, magnesium sulfate, per 500 mg N1 N

IOM: 100-02, 15, 50

❂ J3480 Injection, potassium chloride, per 2 meq N1 N

IOM: 100-02, 15, 50

❂ J3485 Injection, zidovudine, 10 mg N1 N

Other: Retrovir
IOM: 100-02, 15, 50
✽ J3486 Injection, ziprasidone mesylate, 10 mg N1 N

Other: Geodon
✽ J3489 Injection, zoledronic acid, 1 mg N1 N

Other: Reclast, Zometra

❂ J3490 Unclassified drugs N1 N

Bill on paper. Bill one unit. Identify drug and total dosage in
“Remarks” field.
 Other: Acthib, Aminocaproic Acid, Baciim, Bacitracin, Benzocaine,
Bumetanide, Bupivacaine, Cefotetan, Ciprofloxacin, Cleocin
Phosphate, Clindamycin, Cortisone Acetate Micronized, Definity,
Diprivan, Doxy, Engerix-B, Ethanolamine, Famotidine, Ganirelix,
Gonal-F, Hyaluronic Acid, Marcaine, Metronidazole, Nafcillin,
Naltrexone, Ovidrel, Pegasys, Peg-Intron, Penicillin G Sodium,
Propofol, Protonix, Recombivax, Rifadin, Rifampin, Sensorcaine-
MPF, Smz-TMP, Sufentanil Citrate, Testopel Pellets, Testosterone,
Treanda, Valcyte, Veritas Collagen Matrix
IOM: 100-02, 15, 50
Coding Clinic: 2017, Q1, P1-3, P8; 2014, Q2, P6; 2013, Q2, P3-4
J3520 Edetate disodium, per 150 mg E1

Other: Chealamide, Disotate, Endrate ethylenediamine-tetra-acetic

IOM: 100-03, 1, 20.21; 100-03, 1, 20.22
❂ J3530 Nasal vaccine inhalation N1 N

IOM: 100-02, 15, 50

J3535 Drug administered through a metered dose inhaler E1

Other: Ipratropium bromide

IOM: 100-02, 15, 50
J3570 Laetrile, amygdalin, vitamin B-17 E1

IOM: 100-03, 1, 30.7

✽ J3590 Unclassified biologics N1 N

Bill on paper. Bill one unit. Identify drug and total dosage in
“Remarks” field.
Coding Clinic: 2017, Q1, P1-3; 2016, Q4, P10
✽ J3591 Unclassified drug or biological used for ESRD on dialysis B

❂ J7030 Infusion, normal saline solution, 1000 cc N1 N

Other: Sodium Chloride

IOM: 100-02, 15, 50
❂ J7040 Infusion, normal saline solution, sterile (500 ml = 1 unit)
Other: Sodium Chloride
IOM: 100-02, 15, 50
N1 N
❂ J7042 5% dextrose/normal saline (500 ml = 1 unit) N1 N

Other: Dextrose-Nacl
IOM: 100-02, 15, 50
❂ J7050 Infusion, normal saline solution, 250 cc N1 N
 Other: Sodium Chloride
IOM: 100-02, 15, 50
❂ J7060 5% dextrose/water (500 ml = 1 unit) N1 N

IOM: 100-02, 15, 50

❂ J7070 Infusion, D 5 W, 1000 cc N1 N

Other: Dextrose
IOM: 100-02, 15, 50
❂ J7100 Infusion, dextran 40, 500 ml N1 N

Other: Gentran, LMD, Rheomacrodex

IOM: 100-02, 15, 50
❂ J7110 Infusion, dextran 75, 500 ml N1 N

Other: Gentran 75
IOM: 100-02, 15, 50
❂ J7120 Ringer’s lactate infusion, up to 1000 cc N1 N

Replacement fluid or electrolytes.

Other: Potassium Chloride
IOM: 100-02, 15, 50
❂ J7121 5% dextrose in lactated ringers infusion, up to 1000 cc
N1 N
IOM: 100-02, 15, 50
❂ J7131 Hypertonic saline solution, 1 ml N1 N

IOM: 100-02, 15, 50

Coding Clinic: 2012, Q1, P9

Clotting Factors
✽ J7168 Prothrombin complex concentrate (human), kcentra, per i.u. of
factor ix activity K2 K

✽ J7169 Injection, coagulation factor xa (recombinant), inactivated-zhzo

(andexxa), 10 mg K2 G

✽ J7170 Injection, emicizumab-kxwh, 0.5 mg G

Other: Hemlibra
✽ J7175 Injection, Factor X, (human), 1 IU K2 K
Coding Clinic: 2017, Q1, P9
✽ J7177 Injection, human fibrinogen concentrate (fibryga), 1 mg K

✽ J7178 Injection, human fibrinogen concentrate, not otherwise specified, 1

 mg K2 K

Other: Riastap
❂ J7179 Injection, von Willebrand factor (recombinant), (vonvendi), 1 IU
VWF:RCo K2 G
Coding Clinic: 2017, Q1, P9
✽ J7180 Injection, factor XIII (antihemophilic factor, human), 1 IU
K2 K
Other: Corifact
Coding Clinic: 2012, Q1, P8
✽ J7181 Injection, factor XIII a-subunit, (recombinant), per IU
K2 K
✽ J7182 Injection, factor VIII, (antihemophilic factor, recombinant),
(novoeight), per IU K2 K

❂ J7183 Injection, von Willebrand factor complex (human), wilate, 1 IU

VWF:RCo K2 K

IOM: 100-02, 15, 50

Coding Clinic: 2012, Q1, P9
✽ J7185 Injection, Factor VIII (antihemophilic factor, recombinant)
(Xyntha), per IU K2 K

❂ J7186 Injection, anti-hemophilic factor VIII/von Willebrand factor

complex (human), per factor VIII IU K2 K

Other: Alphanate
IOM: 100-02, 15, 50
❂ J7187 Injection, von Willebrand factor complex (HUMATE-P), per IU
VWF:RCo K2 K

Other: Humate-P Low Dilutent

IOM: 100-02, 15, 50
❂ J7188 Injection, factor VIII (antihemophilic factor, recombinant), (obizur),
per IU K2 K

IOM: 100-02, 15, 50

❂ J7189 Factor VIIa (anti-hemophilic factor, recombinant), (novoseven rt),
per 1 mcg K2 K

Other: NovoSeven
IOM: 100-02, 15, 50
❂ J7190 Factor VIII anti-hemophilic factor, human, per IU K2 K

Other: Alphanate/von Willebrand factor complex, Hemofil M, Koate

DVI, Koate-HP, Kogenate, Monoclate-P, Recombinate
IOM: 100-02, 15, 50
❂ J7191 Factor VIII, anti-hemophilic factor (porcine), per IU E2

Other: Hyate:C, Koate-HP, Kogenate, Monoclate-P, Recombinate

IOM: 100-02, 15, 50
❂ J7192 Factor VIII (anti-hemophilic factor, recombinant) per IU, not
otherwise specified K2 K

Other: Advate, Helixate FS, Kogenate FS, Koate-HP, Recombinate,

Xyntha
IOM: 100-02, 15, 50
❂ J7193 Factor IX (anti-hemophilic factor, purified, non-recombinant) per IU
K2 K

Other: AlphaNine SD, Mononine, Proplex

IOM: 100-02, 15, 50
❂ J7194 Factor IX, complex, per IU K2 K

Other: Bebulin, Konyne-80, Profilnine Heat-treated, Profilnine SD,

Proplex SXT, Proplex T
IOM: 100-02, 15, 50
❂ J7195 Injection, Factor IX (anti-hemophilic factor, recombinant) per IU,
not otherwise specified K2 K

Other: Benefix, Profiline, Proplex T

IOM: 100-02, 15, 50
✽ J7196 Injection, antithrombin recombinant, 50 IU E2

Other: ATryn, Feiba VH Immuno

Coding Clinic: 2011, Q1, P6
❂ J7197 Anti-thrombin III (human), per IU K2 K

Other: Thrombate III

IOM: 100-02, 15, 50
❂ J7198 Anti-inhibitor, per IU K2 K

Diagnosis examples: D66 Congenital Factor VIII disorder; D67

Congenital Factor IX disorder; D68.0 VonWillebrand’s disease
Other: Autoplex T, Feiba NF, Hemophilia clotting factors
IOM: 100-02, 15, 50; 100-03, 2, 110.3
❂ J7199 Hemophilia clotting factor, not otherwise classified B

Other: Autoplex T
IOM: 100-02, 15, 50; 100-03, 2, 110.3
❂ J7200 Injection, factor IX, (antihemophilic factor, recombinant), rixubis,
per IU K2 K
 IOM: 100-02, 15, 50
❂ J7201 Injection, factor IX, fc fusion protein (recombinant), alprolix, 1 IU
K2 K

IOM: 100-02, 15, 50

❂ J7202 Injection, Factor IX, albumin fusion protein, (recombinant),
idelvion, 1 IU K2 G
Coding Clinic: 2016, Q4, P9
❂ J7203 Injection factor ix, (antihemophilic factor, recombinant),
glycopegylated, (rebinyn), 1 iu G

Other: Profilnine SD, Bebulin VH, Bebulin, Proplex T

❂ J7204 Injection, factor viii, antihemophilic factor (recombinant),
(esperoct), glycopegylated-exei, per iu K2 G

❂ J7205 Injection, factor VIII Fc fusion protein (recombinant), per IU

K2 K
Other: Eloctate
❂ J7207 Injection, Factor VIII, (antihemophilic factor, recombinant),
PEGylated, 1 IU K2 G

Other: Adynovate
❂ J7208 Injection, Factor VIII, (antihemophilic factor, recombinant),
pegylated-aucl, (jivi), 1 i.u. K2 G

✽ J7209 Injection, Factor VIII, (antihemophilic factor, recombinant),

(Nuwiq), 1 IU K2 G

✽ J7210 Injection, Factor VIII, (antihemophilic factor, recombinant),

(afstyla), 1 i.u. K2 G

✽ J7211 Injection, Factor VIII, (antihemophilic factor, recombinant),

(kovaltry), 1 i.u. K2 K

J7212 Factor viia (antihemophilic factor, recombinant)-jncw (sevenfact), 1

microgram K2 K
Contraceptives
J7294 Segesterone acetate and ethinyl estradiol 0.15mg, 0.013mg per 24
hours; yearly vaginal system, each E1

J7295 Ethinyl estradiol and etonogestrel 0.015mg, 0.12mg per 24 hours;

monthly vaginal ring, each E1

J7296 Levonorgestrel-releasing intrauterine contraceptive system

(Kyleena), 19.5 mg ♀ E1

Medicare Statute 1862(a)(1)

Cross Reference Q9984
J7297 Levonorgestrel-releasing intrauterine contraceptive system (Liletta),
52 mg ♀ E1

Medicare Statute 1862(a)(1)

J7298 Levonorgestrel-releasing intrauterine contraceptive system
(Mirena), 52 mg ♀ E1

Medicare Statute 1862(a)(1)

J7300 Intrauterine copper contraceptive ♀ E1

Report IUD insertion with 58300. Bill usual and customary charge.
Other: Paragard T 380 A
Medicare Statute 1862a1
J7301 Levonorgestrel-releasing intrauterine contraceptive system (Skyla),
13.5 mg ♀ E1

Medicare Statute 1862(a)(1)

J7304 Contraceptive supply, hormone containing patch, each ♀ E1

Only billed by Family Planning Clinics

Medicare Statute 1862.1
J7306 Levonorgestrel (contraceptive) implant system, including implants
and supplies ♀ E1

J7307 Etonogestrel (contraceptive) implant system, including implant and

supplies ♀ E1

Aminolevulinic Acid HCL

✽ J7308 Aminolevulinic acid HCL for topical administration, 20%, single
unit dosage form (354 mg) K2 K

Other: Levulan Kerastick

 ❂ J7309 Methyl aminolevulinate (MAL) for topical administration, 16.8%, 1
gram N1 N

Other: Metvixia
Coding Clinic: 2011, Q1, P6

Ganciclovir
❂ J7310 Ganciclovir, 4.5 mg, long-acting implant E2

IOM: 100-02, 15, 50

Ophthalmic Drugs
✽ J7311 Injection, fluocinolone acetonide, intravitreal implant (retisert), 0.01
mg K2 K

Treatment of chronic noninfectious posterior segment uveitis

Other: Retisert
✽ J7312 Injection, dexamethasone, intravitreal implant, 0.1 mg
K2 K
To bill for Ozurdex services submit the following codes:
J7312 and 67028 with the modifier -22 (for the increased work
difficulty and increased risk). Indicated for the treatment of macular
edema occurring after branch retinal vein occlusion (BRVO) or
central retinal vein occlusion (CRVO) and noninfectious uveitis
affecting the posterior segment of the eye.
Other: Ozurdex
Coding Clinic: 2011, Q1, P7
✽ J7313 Injection, fluocinolone acetonide, intravitreal implant (iluvien), 0.01
mg K2 K

Other: Iluvien
✽ J7314 Injection, fluocinolone acetonide, intravitreal implant (yutiq), 0.01
mg K2 G

✽ J7315 Mitomycin, ophthalmic, 0.2 mg N1 N

Other: Mitosol, Mutamycin

Coding Clinic: 2016, Q4, P8; 2014, Q2, P6
✽ J7316 Injection, ocriplasmin, 0.125 mg K2 K

Other: Jetrea

Hyaluronan
✽ J7318 Hyaluronan or derivative, durolane, for intra-articular injection, 1
mg G
 Other: Morisu
✽ J7320 Hyaluronan or derivitive, genvisc 850, for intra-articular injection, 1
mg K2 K

✽ J7321 Hyaluronan or derivative, Hyalgan, Supartz or Visco-3, for intra-

articular injection, per dose K2 K

Therapeutic goal is to restore viscoelasticity of synovial hyaluronan,

thereby decreasing pain, improving mobility and restoring natural
protective functions of hyaluronan in joint
✽ J7322 Hyaluronan or derivative, hymovis, for intra-articular injection, 1
mg K2 G

✽ J7323 Hyaluronan or derivative, Euflexxa, for intra-articular injection, per

dose K2 K

✽ J7324 Hyaluronan or derivative, Orthovisc, for intra-articular injection, per

dose K2 K

✽ J7325 Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-

articular injection, 1 mg K2 K

✽ J7326 Hyaluronan or derivative, Gel-One, for intra-articular injection, per

dose K2 K
Coding Clinic: 2012, Q1, P8
✽ J7327 Hyaluronan or derivative, monovisc, for intra-articular injection, per
dose K2 K

✽ J7328 Hyaluronan or derivative, gelsyn-3, for intra-articular injection, 0.1

mg K2 G

✽ J7329 Hyaluronan or derivative, trivisc, for intra-articular injection, 1 mg

E2

Miscellaneous Drugs
✽ J7330 Autologous cultured chondrocytes, implant B

Other: Carticel
Coding Clinic: 2010, Q4, P3
✽ J7331 Hyaluronan or derivative, synojoynt, for intra-articular injection, 1
mg K

✽ J7332 Hyaluronan or derivative, triluron, for intra-articular injection, 1 mg

K
✽ J7336 Capsaicin 8% patch, per square centimeter K2 K

Other: Qutenza
✽ J7340 Carbidopa 5 mg/levodopa 20 mg enteral suspension, 100 ml
K2 K
 Other: Duopa
✽ J7342 Instillation, ciprofloxacin otic suspension, 6 mg K2 G

❂ J7345 Aminolevulinic acid HCL for topical administration, 10% gel, 10

mg K2 G

✽ J7351 Injection, bimatoprost, intracameral implant, 1 microgram K2 G

✽ J7352 Afamelanotide implant, 1 mg K2 K

✽ J7402 Mometasone furoate sinus implant, (sinuva), 10 micrograms K2 G

Immunosuppressive Drugs (Includes Non-injectibles)

❂ J7500 Azathioprine, oral, 50 mg N1 N

Other: Azasan, Imuran

IOM: 100-02, 15, 50
❂ J7501 Azathioprine, parenteral, 100 mg K2 K

Other: Imuran
IOM: 100-02, 15, 50
❂ J7502 Cyclosporine, oral, 100 mg N1 N

Other: Gengraf, Neoral, Sandimmune

IOM: 100-02, 15, 50
❂ J7503 Tacrolimus, extended release, (Envarsus XR), oral, 0.25 mg
K2 G
IOM: 100-02, 15, 50
❂ J7504 Lymphocyte immune globulin, antithymocyte globulin, equine,
parenteral, 250 mg K2 K

Other: Atgam
IOM: 100-02, 15, 50; 100-03, 2, 110.3
❂ J7505 Muromonab-CD3, parenteral, 5 mg K2 K

Other: Monoclonal antibodies (parenteral)

IOM: 100-02, 15, 50
❂ J7507 Tacrolimus, immediate release, oral, 1 mg N1 N

Other: Prograf
IOM: 100-02, 15, 50
❂ J7508 Tacrolimus, extended release, (Astagraf XL), oral, 0.1 mg
N1 N
IOM: 100-02, 15, 50
❂ J7509 Methylprednisolone oral, per 4 mg N1 N
 Other: Medrol
IOM: 100-02, 15, 50
❂ J7510 Prednisolone oral, per 5 mg N1 N

Other: Delta-Cortef, Flo-Pred, Orapred

IOM: 100-02, 15, 50
✽ J7511 Lymphocyte immune globulin, antithymocyte globulin, rabbit,
parenteral, 25 mg K2 K

Other: Thymoglobulin
❂ J7512 Prednisone, immediate release or delayed release, oral, 1 mg
N1 N
Other: Cyclosporine
IOM: 100-02, 15, 50
❂ J7513 Daclizumab, parenteral, 25 mg E2

Other: Zenapax
IOM: 100-02, 15, 50
✽ J7515 Cyclosporine, oral, 25 mg N1 N

Other: Gengraf, Neoral, Sandimmune

✽ J7516 Cyclosporin, parenteral, 250 mg N1 N

Other: Sandimmune
✽ J7517 Mycophenolate mofetil, oral, 250 mg N1 N

Other: CellCept
❂ J7518 Mycophenolic acid, oral, 180 mg N1 N

Other: Myfortic
IOM: 100-04, 4, 240; 100-4, 17, 80.3.1
❂ J7520 Sirolimus, oral, 1 mg N1 N

Other: Rapamune
IOM: 100-02, 15, 50
❂ J7525 Tacrolimus, parenteral, 5 mg K2 K

Other: Prograf
IOM: 100-02, 15, 50
❂ J7527 Everolimus, oral, 0.25 mg N1 N

Other: Zortress
IOM: 100-02, 15, 50
❂ J7599 Immunosuppressive drug, not otherwise classified N1 N

Bill on paper. Bill one unit. Identify drug and total dosage in
 “Remarks” field.
IOM: 100-02, 15, 50

Inhalation Solutions
✽ J7604 Acetylcysteine, inhalation solution, compounded product,
administered through DME, unit dose form, per gram M

Other: Mucomyst (unit dose form), Mucosol

✽ J7605 Arformoterol, inhalation solution, FDA approved final product, non-
compounded, administered through DME, unit dose form, 15 mcg
M

Maintenance treatment of bronchoconstriction in patients with

chronic obstructive pulmonary disease (COPD).
Other: Brovana
✽ J7606 Formoterol fumarate, inhalation solution, FDA approved final
product, non-compounded, administered through DME, unit dose
form, 20 mcg M

Other: Perforomist
✽ J7607 Levalbuterol, inhalation solution, compounded product,
administered through DME, concentrated form, 0.5 mg
M
❂ J7608 Acetylcysteine, inhalation solution, FDA-approved final product,
noncompounded, administered through DME, unit dose form, per
gram M

Other: Mucomyst, Mucosol

✽ J7609 Albuterol, inhalation solution, compounded product, administered
through DME, unit dose, 1 mg M

Patient’s home, medications—such as a albuterol when administered

through a nebulizer—are considered DME and are payable under
Part B.
Other: Proventil, Ventolin, Xopenex
✽ J7610 Albuterol, inhalation solution, compounded product, administered
through DME, concentrated form, 1 mg M

Other: Proventil, Ventolin, Xopenex

❂ J7611 Albuterol, inhalation solution, FDA-approved final product, non-
compounded, administered through DME, concentrated form, 1 mg
M

Report once for each milligram administered. For example, 2 mg of

concentrated albuterol (usually diluted with saline), reported with
 J7611×2.
Other: Proventil, Ventolin, Xopenex
❂ J7612 Levalbuterol, inhalation solution, FDA-approved final product, non-
compounded, administered through DME, concentrated form, 0.5
mg M

Other: Xopenex
❂ J7613 Albuterol, inhalation solution, FDA-approved final product, non-
compounded, administered through DME, unit dose, 1 mg
M
Other: Accuneb, Proventil, Ventolin, Xopenex
❂ J7614 Levalbuterol, inhalation solution, FDA-approved final product, non-
compounded, administered through DME, unit dose, 0.5 mg
M
Other: Xopenex
✽ J7615 Levalbuterol, inhalation solution, compounded product,
administered through DME, unit dose, 0.5 mg M

❂ J7620 Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg,

FDA-approved final product, non-compounded, administered
through DME M

Other: DuoNeb
✽ J7622 Beclomethasone, inhalation solution, compounded product,
administered through DME, unit dose form, per mg M

✽ J7624 Betamethasone, inhalation solution, compounded product,

administered through DME, unit dose form, per mg M

✽ J7626 Budesonide inhalation solution, FDA-approved final product, non-

compounded, administered through DME, unit dose form, up to 0.5
mg M

Other: Pulmicort
✽ J7627 Budesonide, inhalation solution, compounded product, administered
through DME, unit dose form, up to 0.5 mg M

Other: Pulmicort Respules

❂ J7628 Bitolterol mesylate, inhalation solution, compounded product,
administered through DME, concentrated form, per milligram
M

Other: Tornalate
❂ J7629 Bitolterol mesylate, inhalation solution, compounded product,
administered through DME, unit dose form, per milligram
M
 Other: Tornalate
❂ J7631 Cromolyn sodium, inhalation solution, FDA-approved final product,
non-compounded, administered through DME, unit dose form, per
10 mg M

Other: Intal
✽ J7632 Cromolyn sodium, inhalation solution, compounded product,
administered through DME, unit dose form, per 10 mg
M
Other: Intal
✽ J7633 Budesonide, inhalation solution, FDA-approved final product, non-
compounded, administered through DME, concentrated form, per
0.25 mg M

Other: Pulmicort Respules

✽ J7634 Budesonide, inhalation solution, compounded product, administered
through DME, concentrated form, per 0.25 mg M

Other: Pulmicort Respules

❂ J7635 Atropine, inhalation solution, compounded product, administered
through DME, concentrated form, per milligram M

❂ J7636 Atropine, inhalation solution, compounded product, administered

through DME, unit dose form, per milligram M

❂ J7637 Dexamethasone, inhalation solution, compounded product,

administered through DME, concentrated form, per milligram
M

❂ J7638 Dexamethasone, inhalation solution, compounded product,

administered through DME, unit dose form, per milligram
M
❂ J7639 Dornase alfa, inhalation solution, FDA-approved final product, non-
compounded, administered through DME, unit dose form, per
milligram M

Other: Pulmozyme
✽ J7640 Formoterol, inhalation solution, compounded product, administered
through DME, unit dose form, 12 mcg E1

✽ J7641 Flunisolide, inhalation solution, compounded product, administered

through DME, unit dose, per milligram M

❂ J7642 Glycopyrrolate, inhalation solution, compounded product,

administered through DME, concentrated form, per milligram
M

❂ J7643 Glycopyrrolate, inhalation solution, compounded product,

administered through DME, unit dose form, per milligram
 M
❂ J7644 Ipratropium bromide, inhalation solution, FDA-approved final
product, non-compounded, administered through DME, unit dose
form, per milligram M

Other: Atrovent
✽ J7645 Ipratropium bromide, inhalation solution, compounded product,
administered through DME, unit dose form, per milligram
M
Other: Atrovent
✽ J7647 Isoetharine HCL, inhalation solution, compounded product,
administered through DME, concentrated form, per milligram
M

Other: Bronkosol
❂ J7648 Isoetharine HCL, inhalation solution, FDA-approved final product,
noncompounded, administered through DME, concentrated form,
per milligram M

Other: Bronkosol
❂ J7649 Isoetharine HCL, inhalation solution, FDA-approved final product,
noncompounded, administered through DME, unit dose form, per
milligram M

Other: Bronkosol
✽ J7650 Isoetharine HCL, inhalation solution, compounded product,
administered through DME, unit dose form, per milligram
M
Other: Bronkosol
✽ J7657 Isoproterenol HCL, inhalation solution, compounded product,
administered through DME, concentrated form, per milligram
M

Other: Isuprel
❂ J7658 Isoproterenol HCL inhalation solution, FDA-approved final product,
noncompounded, administered through DME, concentrated form,
per milligram M

Other: Isuprel
❂ J7659 Isoproterenol HCL, inhalation solution, FDA-approved final
product, noncompounded, administered through DME, unit dose
form, per milligram M

Other: Isuprel
✽ J7660 Isoproterenol HCL, inhalation solution, compounded product,
 administered through DME, unit dose form, per milligram
M
Other: Isuprel
✽ J7665 Mannitol, administered through an inhaler, 5 mg N1 N

Other: Aridol
✽ J7667 Metaproterenol sulfate, inhalation solution, compounded product,
concentrated form, per 10 mg M

Other: Alupent, Metaprel

❂ J7668 Metaproterenol sulfate, inhalation solution, FDA-approved final
product, non-compounded, administered through DME,
concentrated form, per 10 mg M

Other: Alupent, Metaprel

❂ J7669 Metaproterenol sulfate, inhalation solution, FDA-approved final
product, non-compounded, administered through DME, unit dose
form, per 10 mg M

Other: Alupent, Metaprel

✽ J7670 Metaproterenol sulfate, inhalation solution, compounded product,
administered through DME, unit dose form, per 10 mg
M
Other: Alupent, Metaprel
✽ J7674 Methacholine chloride administered as inhalation solution through a
nebulizer, per 1 mg N1 N

Other: Provocholine
✽ J7676 Pentamidine isethionate, inhalation solution, compounded product,
administered through DME, unit dose form, per 300 mg
M
Other: NebuPent, Pentam
✽ J7677 Revefenacin inhalation solution, FDA-approved final product, non-
compounded, administered through DME, 1 microgram M

❂ J7680 Terbutaline sulfate, inhalation solution, compounded product,

administered through DME, concentrated form, per milligram
M

Other: Brethine
❂ J7681 Terbutaline sulfate, inhalation solution, compounded product,
administered through DME, unit dose form, per milligram
M
Other: Brethine
❂ J7682 Tobramycin, inhalation solution, FDA-approved final product, non-
compounded unit dose form, administered through DME, per 300
 mg M

Other: Bethkis, Kitabis PAK, Tobi

❂ J7683 Triamcinolone, inhalation solution, compounded product,
administered through DME, concentrated form, per milligram
M

❂ J7684 Triamcinolone, inhalation solution, compounded product,

administered through DME, unit dose form, per milligram
M
Other: Triamcinolone acetonide
✽ J7685 Tobramycin, inhalation solution, compounded product, administered
through DME, unit dose form, per 300 mg M

Other: Tobi
✽ J7686 Treprostinil, inhalation solution, FDA-approved final product, non-
compounded, administered through DME, unit dose form, 1.74 mg
M

Other: Tyvaso

Not Otherwise Classified/Specified

❂ J7699 NOC drugs, inhalation solution administered through DME M

Other: Gentamicin Sulfate

❂ J7799 NOC drugs, other than inhalation drugs, administered through DME
N1 N

Bill on paper. Bill one unit and identify drug and total dosage in the
“Remark” field.
Other: Cuvitru, Epinephrine, Mannitol, Osmitrol, Phenylephrine,
Resectisol, Sodium chloride
IOM: 100-02, 15, 110.3
❂ J7999 Compounded drug, not otherwise classified N1 N
Coding Clinic: 2017, Q1, P1-2; 2016, Q4, P8
❂ J8498 Antiemetic drug, rectal/suppository, not otherwise specified B

Other: Compazine, Compro, Phenadoz, Phenergan,

Prochlorperazine, Promethazine, Promethegan
Medicare Statute 1861(s)2t
J8499 Prescription drug, oral, non chemotherapeutic, NOS E1

Other: Acyclovir, Calcitrol, Cromolyn Sodium, OFEV,

Valganciclovir HCL, Zovirax
IOM: 100-02, 15, 50
 Coding Clinic: 2013, Q2, P4

Oral Anti-Cancer Drugs

❂ J8501 Aprepitant, oral, 5 mg K2 K

Other: Emend
❂ J8510 Busulfan; oral, 2 mg N1 N

Other: Myleran
IOM: 100-02, 15, 50; 100-04, 4, 240; 100-04, 17, 80.1.1
J8515 Cabergoline, oral, 0.25 mg E1

IOM: 100-02, 15, 50; 100-04, 4, 240

❂ J8520 Capecitabine, oral, 150 mg N1 N

Other: Xeloda
IOM: 100-02, 15, 50; 100-04, 4, 240; 100-04, 17, 80.1.1
❂ J8521 Capecitabine, oral, 500 mg N1 N

Other: Xeloda
IOM: 100-02, 15, 50; 100-04, 4, 240; 100-04, 17, 80.1.1
❂ J8530 Cyclophosphamide; oral, 25 mg N1 N

Other: Cytoxan
IOM: 100-02, 15, 50; 100-04, 4, 240; 100-04, 17, 80.1.1
❂ J8540 Dexamethasone, oral, 0.25 mg N1 N

Other: Decadron, Dexone, Dexpak, Locort

Medicare Statute 1861(s)2t
❂ J8560 Etoposide; oral, 50 mg K2 K

Other: VePesid
IOM: 100-02, 15, 50; 100-04, 4, 230.1; 100-04, 4, 240; 100-04, 17,
80.1.1
✽ J8562 Fludarabine phosphate, oral, 10 mg E2

Other: Fludara, Oforta

Coding Clinic: 2011, Q1, P9
❂ J8565 Gefitinib, oral, 250 mg E2

Other: Iressa
❂ J8597 Antiemetic drug, oral, not otherwise specified N1 N

Medicare Statute 1861(s)2t

❂ J8600 Melphalan; oral, 2 mg N1 N

Other: Alkeran
 IOM: 100-02, 15, 50; 100-04, 4, 240; 100-04, 17, 80.1.1
❂ J8610 Methotrexate; oral, 2.5 mg N1 N

Other: Rheumatrex, Trexall

IOM: 100-02, 15, 50; 100-04, 4, 240; 100-04, 17, 80.1.1
✽ J8650 Nabilone, oral, 1 mg E2

❂ J8655 Netupitant 300 mg and palonosetron 0.5 mg, oral K2 K

Other: Akynzeo
Coding Clinic: 2015, Q4, P4
❂ J8670 Rolapitant, oral, 1 mg K2 K

Other: Varubi
❂ J8700 Temozolomide, oral, 5 mg N1 N

Other: Temodar
IOM: 100-02, 15, 50; 100-04, 4, 240
✽ J8705 Topotecan, oral, 0.25 mg K2 K

Treatment for ovarian and lung cancers, etc. Report J9350

(Topotecan, 4 mg) for intravenous version
Other: Hycamtin
❂ J8999 Prescription drug, oral, chemotherapeutic, NOS B

Other: Anastrozole, Arimidex, Aromasin, Droxia, Erivedge,

Flutamide, Gleevec, Hydrea, Hydroxyurea, Leukeran, Matulane,
Megestrol Acetate, Mercaptopurine, Nolvadex, Tamoxifen Citrate
IOM: 100-02, 15, 50; 100-04, 4, 250; 100-04, 17, 80.1.1; 100-04,
17, 80.1.2

CHEMOTHERAPY DRUGS (J9000-J9999)

NOTE: These codes cover the cost of the chemotherapy drug only, not to include
the administration
❂ J9000 Injection, doxorubicin hydrochloride, 10 mg N1 N

Other: Adriamycin, Rubex

IOM: 100-02, 15, 50
Coding Clinic: 2007, Q4, P5
❂ J9015 Injection, aldesleukin, per single use vial K2 K

Other: Proleukin
IOM: 100-02, 15, 50
✽ J9017 Injection, arsenic trioxide, 1 mg K2 K

Other: Trisenox
❂ J9019 Injection, asparaginase (Erwinaze), 1,000 IU K2 K

IOM: 100-02, 15, 50

❂ J9020 Injection, asparaginase, not otherwise specified 10,000 units
N1 N
IOM: 100-02, 15, 50
J9021 Injection, asparaginase, recombinant, (rylaze), 0.1 mg K2 G

✽ J9022 Injection, atezolizumab, 10 mg K2 G

✽ J9023 Injection, avelumab, 10 mg K2 G

✽ J9025 Injection, azacitidine, 1 mg K2 K

✽ J9027 Injection, clofarabine, 1 mg K2 K

Other: Clolar
❂ J9030 BCG live intravesical instillation, 1 mg K2 K

✽ J9032 Injection, belinostat, 10 mg K2 K

Other: Beleodaq
✽ J9033 Injection, bendamustine HCL (treanda), 1 mg K2 K

Treatment for form of non-Hodgkin’s lymphoma; standard

administration time is as an intravenous infusion over 30 minutes
Other: Treanda
✽ J9034 Injection, bendamustine HCL (bendeka), 1 mg K2 G
Coding Clinic: 2017, Q1, P10
✽ J9035 Injection, bevacizumab, 10 mg K2 K

For malignant neoplasm of breast, considered J9207.

Other: Avastin
Coding Clinic: 2013, Q3, P9, Q2, P8
✽ J9036 Injection, bendamustine hydrochloride, (belrapzo/bendamustine), 1
mg K2 G

✽ J9037 Injection, belantamab mafodontinblmf, 0.5 mg K2 G

✽ J9039 Injection, blinatumomab, 1 mcg K2 K

Other: Blincyto
❂ J9040 Injection, bleomycin sulfate, 15 units N1 N

Other: Blenoxane
IOM: 100-02, 15, 50
✽ J9041 Injection, bortezomib, 0.1 mg K2 K
 Other: Velcade
✽ J9042 Injection, brentuximab vedotin, 1 mg K2 K

Other: Adcetris
✽ J9043 Injection, cabazitaxel, 1 mg K2 K

Other: Jevtana
Coding Clinic: 2012, Q1, P9
J9044 Injection, bortezomib, not otherwise specified, 0.1 mg ✖
Other: Velcade
❂ J9045 Injection, carboplatin, 50 mg N1 N

Other: Paraplatin
IOM: 100-02, 15, 50
▶ J9046 Injection, bortezomib, (Dr. Reddy’s), not therapeutically equivalent
to J9041, 0.1 mg K2 K

✽ J9047 Injection, carfilzomib, 1 mg K2 K

Other: Kyprolis
▶ J9048 Injection, bortezomib (fresenius kabi), not therapeutically equivalent
to J9041, 0.1 mg K2 K

▶ J9049 Injection, bortezomib (hospira), not therapeutically equivalent to

J9041, 0.1 mg K2 K

❂ J9050 Injection, carmustine, 100 mg K2 K

Other: BiCNU
IOM: 100-02, 15, 50
✽ J9055 Injection, cetuximab, 10 mg K2 K

Other: Erbitux
✽ J9057 Injection, copanlisib, 1 mg G

Other: Aliqopa
❂ J9060 Injection, cisplatin, powder or solution, 10 mg N1 N

Other: Plantinol AQ
IOM: 100-02, 15, 50
Coding Clinic: 2013, Q2, P6; 2011, Q1, P8
✽ J9061 Injection, amivantamab-vmjw, 2 mg K2 G

❂ J9065 Injection, cladribine, per 1 mg K2 K

Other: Leustatin
IOM: 100-02, 15, 50
❂ J9070 Cyclophosphamide, 100 mg K2 K
 Other: Cytoxan, Neosar
IOM: 100-02, 15, 50
Coding Clinic: 2011, Q1, P8-9
✽ J9098 Injection, cytarabine liposome, 10 mg K2 K

Other: DepoCyt
❂ J9100 Injection, cytarabine, 100 mg N1 N

Other: Cytosar-U
IOM: 100-02, 15, 50
Coding Clinic: 2011, Q1, P9
✽ J9118 Injection, calaspargase pegol-mknl, 10 units E2

✽ J9119 Injection, cemiplimab-rwlc, 1 mg K2 G

❂ J9120 Injection, dactinomycin, 0.5 mg K2 K

Other: Cosmegen
IOM: 100-02, 15, 50
❂ J9130 Dacarbazine, 100 mg N1 N

Other: DTIC-Dome
IOM: 100-02, 15, 50
Coding Clinic: 2011, Q1, P9
❂ J9144 Injection, daratumumab, 10 mg and hyaluronidase-fihj K2 G

❂ J9145 Injection, daratumumab, 10 mg K2 G

Other: Darzalex
IOM: 100-02, 15, 50
❂ J9150 Injection, daunorubicin, 10 mg K2 K

Other: Cerubidine
IOM: 100-02, 15, 50
❂ J9151 Injection, daunorubicin citrate, liposomal formulation, 10 mg
E2

Other: Daunoxome
IOM: 100-02, 15, 50
✽ J9153 njection, liposomal, 1 mg daunorubicin and 2.27 mg cytarabine G

Other: Vyxeos
✽ J9155 Injection, degarelix, 1 mg K2 K

Report 1 unit for every 1 mg.

Other: Firmagon
Injection, denileukin diftitox, 300 mcg E2
✽ J9160
❂ J9165 Injection, diethylstilbestrol diphosphate, 250 mg E2

Other: Stilphostrol
IOM: 100-02, 15, 50
❂ J9171 Injection, docetaxel, 1 mg K2 K

Report 1 unit for every 1 mg.

Other: Docefrez, Taxotere
IOM: 100-02, 15, 50
Coding Clinic: 2012, Q1, P9
✽ J9173 Injection, durvalumab, 10 mg G

Other: Imfinzi
❂ J9175 Injection, Elliott’s B solution, 1 ml N1 N

IOM: 100-02, 15, 50

✽ J9176 Injection, elotuzumab, 1 mg K2 G

Other: Empliciti
✽ J9177 Injection, enfortumab vedotin-ejfv, 0.25 mg K2 G

✽ J9178 Injection, epirubicin HCL, 2 mg N1 N

Other: Ellence
✽ J9179 Injection, eribulin mesylate, 0.1 mg K2 K

Other: Halaven
❂ J9181 Injection, etoposide, 10 mg N1 N

Other: Etopophos, Toposar

❂ J9185 Injection, fludarabine phosphate, 50 mg K2 K

Other: Fludara
IOM: 100-02, 15, 50
❂ J9190 Injection, fluorouracil, 500 mg N1 N

Other: Adrucil
IOM: 100-02, 15, 50
❂ J9198 Injection, gemcitabine hydrochloride, (infugem), 100 mg K2 G

❂ J9200 Injection, floxuridine, 500 mg N1 N

Other: FUDR
IOM: 100-02, 15, 50
❂ J9201 Injection, gemcitabine hydrochloride, not otherwise specified, 200
mg N1 N
 Other: Gemzar
IOM: 100-02, 15, 50
❂ J9202 Goserelin acetate implant, per 3.6 mg K2 K

Other: Zoladex
IOM: 100-02, 15, 50
✽ J9203 Injection, gemtuzumab ozogamicin, 0.1 mg K2 G

✽ J9204 Injection, mogamulizumab-kpkc, 1 mg K2 G

❂ J9205 Injection, irinotecan liposome, 1 mg K2 G

Other: ONIVYDE
IOM: 100-02, 15, 50
❂ J9206 Injection, irinotecan, 20 mg N1 N

Other: Camptosar
IOM: 100-02, 15, 50
✽ J9207 Injection, ixabepilone, 1 mg K2 K

Other: Ixempra Kit

❂ J9208 Injection, ifosfamide, 1 gm N1 N

Other: Ifex
IOM: 100-02, 15, 50
❂ J9209 Injection, mesna, 200 mg N1 N

Other: Mesnex
IOM: 100-02, 15, 50
✽ J9210 Injection, emapalumab-lzsg, 1 mg K2 G

❂ J9211 Injection, idarubicin hydrochloride, 5 mg K2 K

Other: Idamycin PFS

IOM: 100-02, 15, 50
❂ J9212 Injection, interferon alfacon-1, recombinant, 1 mcg
N1 N
Other: Amgen, Infergen
IOM: 100-02, 15, 50
❂ J9213 Injection, interferon, alfa-2a, recombinant, 3 million units
N1 N
Other: Roferon-A
IOM: 100-02, 15, 50
❂ J9214 Injection, interferon, alfa-2b, recombinant, 1 million units
K2 K
Other: Intron-A
 IOM: 100-02, 15, 50
❂ J9215 Injection, interferon, alfa-n3 (human leukocyte derived), 250,000 IU
E2

Other: Alferon N
IOM: 100-02, 15, 50
❂ J9216 Injection, interferon, gamma-1B, 3 million units K2 K

Other: Actimmune
IOM: 100-02, 15, 50
❂ J9217 Leuprolide acetate (for depot suspension), 7.5 mg K2 K

Other: Eligard, Lupron Depot

IOM: 100-02, 15, 50
Coding Clinic: 2019, Q2, P11; 2015, Q3, P3
❂ J9218 Leuprolide acetate, per 1 mg K2 K

Other: Lupron
IOM: 100-02, 15, 50
Coding Clinic: 2019, Q2, P11; 2015, Q3, P3
❂ J9219 Leuprolide acetate implant, 65 mg E2

Other: Viadur
IOM: 100-02, 15, 50
❂ J9223 Injection, lurbinectedin, 0.1 mg K2 G

❂ J9225 Histrelin implant (Vantas), 50 mg K2 K

IOM: 100-02, 15, 50

❂ J9226 Histrelin implant (Supprelin LA), 50 mg K2 K

Other: Vantas
IOM: 100-02, 15, 50
❂ J9227 Injection, isatuximab-irfc, 10 mg K2 G

✽ J9228 Injection, ipilimumab, 1 mg K2 K

Other: Yervoy
Coding Clinic: 2012, Q1, P9
✽ J9229 Injection, inotuzumab ozogamicin, 0.1 mg G

Other: Besponsa
❂ J9230 Injection, mechlorethamine hydrochloride, (nitrogen mustard), 10
mg K2 K

Other: Mustargen
IOM: 100-02, 15, 50
❂ J9245 Injection, melphalan hydrochloride, not otherwise specified, 50 mg
K2 K

❂ J9246 Injection, melphalan (evomela), 1 mg K2 K

Other: Alkeran, Evomela

IOM: 100-02, 15, 50
❂ J9247 Injection, melphalan flufenamide, 1mg K2 G

❂ J9250 Methotrexate sodium, 5 mg N1 N

Other: Folex
IOM: 100-02, 15, 50
❂ J9260 Methotrexate sodium, 50 mg N1 N

Other: Folex
IOM: 100-02, 15, 50
✽ J9261 Injection, nelarabine, 50 mg K2 K

Other: Arranon
✽ J9262 Injection, omacetaxine mepesuccinate, 0.01 mg K2 K

Other: Synribo
✽ J9263 Injection, oxaliplatin, 0.5 mg N1 N

Eloxatin, platinum-based anticancer drug that destroys cancer cells

Other: Eloxatin
Coding Clinic: 2009, Q1, P10
✽ J9264 Injection, paclitaxel protein-bound particles, 1 mg K2 K

Other: Abraxane
❂ J9266 Injection, pegaspargase, per single dose vial K2 K

Other: Oncaspar
IOM: 100-02, 15, 50
❂ J9267 Injection, paclitaxel, 1 mg N1 N

Other: Taxol
❂ J9268 Injection, pentostatin, 10 mg K2 K

Other: Nipent
IOM: 100-02, 15, 50
✽ J9269 Injection, tagraxofusp-erzs, 10 micrograms K2 G

❂ J9270 Injection, plicamycin, 2.5 mg N1 N

Other: Mithracin
IOM: 100-02, 15, 50
✽ J9271 Injection, pembrolizumab, 1 mg K2 K

Other: Keytruda
J9272 Injection, dostarlimab-gxly, 10 mg K2 G

▶ J9274 Injection, tebentafusp-tebn, 1 microgram K2 K

❂ J9280 Injection, mitomycin, 5 mg K2 K

Other: Mitosol, Mutamycin

IOM: 100-02, 15, 50
Coding Clinic: 2016, Q4, P8; 2014, Q2, P6; 2011, Q1, P9
❂ J9281 Mitomycin pyelocalyceal instillation, 1 mg K2 G

✽ J9285 Injection, olaratumab, 10 mg K2 G

❂ J9293 Injection, mitoxantrone hydrochloride, per 5 mg K2 K

Other: Novantrone
IOM: 100-02, 15, 50
✽ J9295 Injection, necitumumab, 1 mg K2 G

Other: Portrazza
▶ J9298 Injection, nivolumab and relatlimab-rmbw, 3 mg/1 mg K2 K

❂ J9299 Injection, nivolumab, 1 mg K2 K

Other: Opdivo
✽ J9301 Injection, obinutuzumab, 10 mg K2 K

Other: Gazyva
✽ J9302 Injection, ofatumumab, 10 mg K2 K

Other: Arzerra
Coding Clinic: 2011, Q1, P7
✽ J9303 Injection, panitumumab, not otherwise specified, 10 mg
K2 K
Other: Vectibix
✽ J9304 Injection, pemetrexed (pemfexy), 10 mg K5 E2

✽ J9305 Injection, pemetrexed, 10 mg K2 K

Other: Alimta
✽ J9306 Injection, pertuzumab, 1 mg K2 K

Other: Perjeta
✽ J9307 Injection, pralatrexate, 1 mg K2 K

Other: Folotyn
Coding Clinic: 2011, Q1, P7
✽ J9308 Injection, ramucirumab, 5 mg K2 K
 Other: Cyramza
✽ J9309 Injection, polatuzumab vedotin-piiq, 1 mg K2 G

❂ J9311 Injection, rituximab 10 mg and hyaluronidase G

Other: Rituxan
❂ J9312 Injection, rituximab, 10 mg K

Other: Rituxan
✽ J9313 Injection, moxetumomab pasudotoxtdfk, 0.01 mg K2 G

✽ J9316 Injection, pertuzumab, trastuzumab, and hyaluronidase-zzxf, per 10

mg K2 G

✽ J9317 Injection, sacituzumab govitecan-hziy, 2.5 mg K2 G

✽ J9318 Injection, romidepsin, non-lyophilized, 0.1 mg K2 G

✽ J9319 Injection, romidepsin, lyophilized, 0.1 mg K2 G

❂ J9320 Injection, streptozocin, 1 gram K2 K

Other: Zanosar
IOM: 100-02, 15, 50
✽ J9325 Injection, talimogene laherparepvec, per 1 million plaque forming
units K2 G

Other: Imlygic
Coding Clinic: 2019, Q2, P12
✽ J9328 Injection, temozolomide, 1 mg K2 K

Intravenous formulation, not for oral administration

Other: Temodar
✽ J9330 Injection, temsirolimus, 1 mg K2 K

Treatment for advanced renal cell carcinoma; standard

administration is intravenous infusion greater than 30-60 minutes
Other: Torisel
▶ J9331 Injection, sirolimus protein-bound particles, 1 mg K2 K

▶ J9332 Injection, efgartigimod alfa-fcab, 2mg K2 K

❂ J9340 Injection, thiotepa, 15 mg K2 K

Other: Tepadina, Triethylene thio Phosphoramide/T

IOM: 100-02, 15, 50
✽ J9348 Injection, naxitamab-gqgk, 1 mg K2 G

✽ J9349 Injection, tafasitamab-cxix, 2 mg K2 G

✽ J9351 Injection, topotecan, 0.1 mg N1 N

Other: Hycamtin
Coding Clinic: 2011, Q1, P9
✽ J9352 Injection, trabectedin, 0.1 mg K2 G

Other: Yondelis
✽ J9353 Injection, margetuximab-cmkb, 5 mg K2 G

✽ J9354 Injection, ado-trastuzumab emtansine, 1 mg K2 K

Other: Kadcyla
✽ J9355 Injection, trastuzumab, excludes biosimilar, 10 mg
K2 K
Other: Herceptin
✽ J9356 Injection, trastuzumab, 10 mg and hyaluronidase-oysk K2 G

❂ J9357 Injection, valrubicin, intravesical, 200 mg K2 K

Other: Valstar
IOM: 100-02, 15, 50
❂ J9358 Injection, fam-trastuzumab deruxtecan-nxki, 1 mg K2 G

❂ J9360 Injection, vinblastine sulfate, 1 mg N1 N

Other: Alkaban-AQ, Velban, Velsar

IOM: 100-02, 15, 50
❂ J9370 Vincristine sulfate, 1 mg N1 N

Other: Oncovin, Vincasar PFS

IOM: 100-02, 15, 50
Coding Clinic: 2011, Q1, P9
✽ J9371 Injection, vincristine sulfate liposome, 1 mg K2 K

❂ J9390 Injection, vinorelbine tartrate, 10 mg N1 N

Other: Navelbine
IOM: 100-02, 15, 50
▶ J9393 Injection, fulvestrant (teva) not therapeutically equivalent to J9395,
25 mg K2 K

▶ J9394 Injection, fulvestrant (fresenius kabi) not therapeutically equivalent

to J9395, 25 mg K2 K

✽ J9395 Injection, fulvestrant, 25 mg K2 K

Other: Faslodex
✽ J9400 Injection, ziv-aflibercept, 1 mg K2 K

Other: Zaltrap
❂ J9600 Injection, porfimer sodium, 75 mg K2 K
 Other: Photofrin
IOM: 100-02, 15, 50
❂ J9999 Not otherwise classified, antineoplastic drugs N1 N

Bill on paper, bill one unit, and identify drug and total dosage in
“Remarks” field. Include invoice of cost or NDC number in
“Remarks” field.
Other: Imlygic, Yondelis
IOM: 100-02, 15, 50; 100-03, 2, 110.2
Coding Clinic: 2017, Q1, P3; 2013, Q2, P3

TEMPORARY CODES ASSIGNED TO DME REGIONAL

CARRIERS (K0000-K9999)
NOTE: This section contains national codes assigned by CMS on a temporary
basis and for the exclusive use of the durable medical equipment regional
carriers (DMERC).

Wheelchairs and Accessories

✽ K0001 Standard wheelchair Y

Capped rental
✽ K0002 Standard hemi (low seat) wheelchair Y

Capped rental
✽ K0003 Lightweight wheelchair Y

Capped rental
✽ K0004 High strength, lightweight wheelchair Y

Capped rental
✽ K0005 Ultralightweight wheelchair Y

Capped rental. Inexpensive and routinely purchased DME

✽ K0006 Heavy duty wheelchair Y

Capped rental
✽ K0007 Extra heavy duty wheelchair Y

Capped rental
❂ K0008 Custom manual wheelchair/base Y

✽ K0009 Other manual wheelchair/base Y

 Not otherwise classified
✽ K0010 Standard - weight frame motorized/power wheelchair Y

Capped rental. Codes K0010-K0014 are not for manual wheelchairs

with add-on power packs. Use the appropriate code for the manual
wheelchair base provided (K0001-K0009) and code K0460.
✽ K0011 Standard - weight frame motorized/power wheelchair with
programmable control parameters for speed adjustment, tremor
dampening, acceleration control and braking Y

Capped rental. A patient who requires a power wheelchair usually is

totally nonambulatory and has severe weakness of the upper
extremities due to a neurologic or muscular disease/condition.
✽ K0012 Lightweight portable motorized/power wheelchair Y

Capped rental
❂ K0013 Custom motorized/power wheelchair base Y

✽ K0014 Other motorized/power wheelchair base Y

Capped rental
✽ K0015 Detachable, non-adjustable height armrest, replacement only, each
Y

Inexpensive and routinely purchased DME

✽ K0017 Detachable, adjustable height armrest, base, replacement only, each
Y

Inexpensive and routinely purchased DME

✽ K0018 Detachable, adjustable height armrest, upper portion, replacement
only, each Y

Inexpensive and routinely purchased DME

✽ K0019 Arm pad, replacement only, each Y

Inexpensive and routinely purchased DME

✽ K0020 Fixed, adjustable height armrest, pair Y

Inexpensive and routinely purchased DME

✽ K0037 High mount flip-up footrest, each Y

Inexpensive and routinely purchased DME

✽ K0038 Leg strap, each Y

Inexpensive and routinely purchased DME

✽ K0039 Leg strap, H style, each Y

Inexpensive and routinely purchased DME

✽ K0040 Adjustable angle footplate, each Y
 Inexpensive and routinely purchased DME
✽ K0041 Large size footplate, each Y

Inexpensive and routinely purchased DME

✽ K0042 Standard size footplate, replacement only, each Y

Inexpensive and routinely purchased DME

✽ K0043 Footrest, lower extension tube, replacement only, each
Y
Inexpensive and routinely purchased DME
✽ K0044 Footrest, upper hanger bracket, replacement only, each
Y
Inexpensive and routinely purchased DME
✽ K0045 Footrest, complete assembly, replacement only, each Y

Inexpensive and routinely purchased DME

✽ K0046 Elevating legrest, lower extension tube, replacement only, each
Y

Inexpensive and routinely purchased DME

✽ K0047 Elevating legrest, upper hanger bracket, replacement only, each
Y

Inexpensive and routinely purchased DME

✽ K0050 Ratchet assembly, replacement only Y

Inexpensive and routinely purchased DME

✽ K0051 Cam release assembly, footrest or legrests, replacement only, each
Y

Inexpensive and routinely purchased DME

✽ K0052 Swing-away, detachable footrests, replacement only, each
Y
Inexpensive and routinely purchased DME
✽ K0053 Elevating footrests, articulating (telescoping), each Y

Inexpensive and routinely purchased DME

✽ K0056 Seat height less than 17” or equal to or greater than 21” for a high
strength, lightweight, or ultralightweight wheelchair Y

Inexpensive and routinely purchased DME

✽ K0065 Spoke protectors, each Y

Inexpensive and routinely purchased DME

✽ K0069 Rear wheel assembly, complete, with solid tire, spokes or molded,
replacement only, each Y

Inexpensive and routinely purchased DME

 ✽ K0070 Rear wheel assembly, complete, with pneumatic tire, spokes or
molded, replacement only, each Y

Inexpensive and routinely purchased DME

✽ K0071 Front caster assembly, complete, with pneumatic tire, replacement
only, each Y

Caster assembly includes a caster fork (E2396), wheel rim, and tire.
Inexpensive and routinely purchased DME
✽ K0072 Front caster assembly, complete, with semi-pneumatic tire,
replacement only, each Y

Inexpensive and routinely purchased DME

✽ K0073 Caster pin lock, each Y

Inexpensive and routinely purchased DME

✽ K0077 Front caster assembly, complete, with solid tire, replacement only,
each Y

✽ K0098 Drive belt for power wheelchair, replacement only Y

Inexpensive and routinely purchased DME

✽ K0105 IV hanger, each Y

Inexpensive and routinely purchased DME

✽ K0108 Wheelchair component or accessory, not otherwise specified Y

❂ K0195 Elevating leg rests, pair (for use with capped rental wheelchair base)
Y

Medically necessary replacement items are covered if rollabout

chair or transport chair covered
IOM: 100-03, 4, 280.1

Infusion Pump, Supplies, and Batteries

❂ K0455 Infusion pump used for uninterrupted parenteral administration of
medication (e.g., epoprostenol or treprostinol) Y

An EIP may also be referred to as an external insulin pump,

ambulatory pump, or mini-infuser. CMN/DIF required. Frequent
and substantial service DME.
IOM: 100-03, 1, 50.3
❂ K0462 Temporary replacement for patient owned equipment being
repaired, any type Y

Only report for maintenance and service for an item for which initial
claim was paid. The term power mobility device (PMD) includes
 power operated vehicles (POVs) and power wheelchairs (PWCs).
Not otherwise classified.
IOM: 100-04, 20, 40.1
❂ K0552 Supplies for external non-insulin drug infusion pump, syringe type
cartridge, sterile, each Y

Supplies
IOM: 100-03, 1, 50.3
K0553 Supply allowance for therapeutic continuous glucose monitor ✖
(CGM), includes all supplies and accessories, 1 month supply = 1
unit of service
K0554 Receiver (monitor), dedicated, for use with therapeutic glucose ✖
continuous monitor system
✽ K0601 Replacement battery for external infusion pump owned by patient,
silver oxide, 1.5 volt, each Y

Inexpensive and routinely purchased DME

✽ K0602 Replacement battery for external infusion pump owned by patient,
silver oxide, 3 volt, each Y

Inexpensive and routinely purchased DME

Figure 18 Infusion pump.

✽ K0603 Replacement battery for external infusion pump owned by patient,

alkaline, 1.5 volt, each Y

Inexpensive and routinely purchased DME

✽ K0604 Replacement battery for external infusion pump owned by patient,
lithium, 3.6 volt, each Y

Inexpensive and routinely purchased DME

✽ K0605 Replacement battery for external infusion pump owned by patient,
lithium, 4.5 volt, each Y

Inexpensive and routinely purchased DME

Defibrillator and Accessories
✽ K0606 Automatic external defibrillator, with integrated electrocardiogram
analysis, garment type Y

Capped rental
✽ K0607 Replacement battery for automated external defibrillator, garment
type only, each Y

Inexpensive and routinely purchased DME

✽ K0608 Replacement garment for use with automated external defibrillator,
each Y

Inexpensive and routinely purchased DME

✽ K0609 Replacement electrodes for use with automated external
defibrillator, garment type only, each Y

Supplies

Miscellaneous
✽ K0669 Wheelchair accessory, wheelchair seat or back cushion, does not
meet specific code criteria or no written coding verification from
DME PDAC Y

Inexpensive and routinely purchased DME

✽ K0672 Addition to lower extremity orthosis, removable soft interface, all
components, replacement only, each A

Prosthetics/Orthotics
✽ K0730 Controlled dose inhalation drug delivery system Y

Inexpensive and routinely purchased DME

✽ K0733 Power wheelchair accessory, 12 to 24 amp hour sealed lead acid
battery, each (e.g., gel cell, absorbed glassmat) Y

Inexpensive and routinely purchased DME

✽ K0738 Portable gaseous oxygen system, rental; home compressor used to
fill portable oxygen cylinders; includes portable containers,
regulator, flowmeter, humidifier, cannula or mask, and tubing
Y

Oxygen and oxygen equipment

✽ K0739 Repair or nonroutine service for durable medical equipment other
than oxygen equipment requiring the skill of a technician, labor
component, per 15 minutes Y

K0740 Repair or nonroutine service for oxygen equipment requiring the

 skill of a technician, labor component, per 15 minutes E1

✽ K0743 Suction pump, home model, portable, for use on wounds

Y
✽ K0744 Absorptive wound dressing for use with suction pump, home model,
portable, pad size 16 square inches or less A

✽ K0745 Absorptive wound dressing for use with suction pump, home model,
portable, pad size more than 16 square inches but less than or equal
to 48 square inches A

✽ K0746 Absorptive wound dressing for use with suction pump, home model,
portable, pad size greater than 48 square inches A

Power Mobility Devices

✽ K0800 Power operated vehicle, group 1 standard, patient weight capacity
up to and including 300 pounds Y

Power mobility device (PMD) includes power operated vehicles

(POVs) and power wheelchairs (PWCs). Inexpensive and routinely
purchased DME
✽ K0801 Power operated vehicle, group 1 heavy duty, patient weight capacity
301 to 450 pounds Y

Inexpensive and routinely purchased DME

✽ K0802 Power operated vehicle, group 1 very heavy duty, patient weight
capacity 451 to 600 pounds Y

Inexpensive and routinely purchased DME

✽ K0806 Power operated vehicle, group 2 standard, patient weight capacity
up to and including 300 pounds Y

Inexpensive and routinely purchased DME

✽ K0807 Power operated vehicle, group 2 heavy duty, patient weight capacity
301 to 450 pounds Y

Inexpensive and routinely purchased DME

✽ K0808 Power operated vehicle, group 2 very heavy duty, patient weight
capacity 451 to 600 pounds Y

Inexpensive and routinely purchased DME

✽ K0812 Power operated vehicle, not otherwise classified Y

Not otherwise classified.

✽ K0813 Power wheelchair, group 1 standard, portable, sling/solid seat and
back, patient weight capacity up to and including 300 pounds
Y
 Capped rental
✽ K0814 Power wheelchair, group 1 standard, portable, captains chair, patient
weight capacity up to and including 300 pounds Y

Capped rental
✽ K0815 Power wheelchair, group 1 standard, sling/solid seat and back,
patient weight capacity up to and including 300 pounds
Y
Capped rental
✽ K0816 Power wheelchair, group 1 standard, captains chair, patient weight
capacity up to and including 300 pounds Y

Capped rental
✽ K0820 Power wheelchair, group 2 standard, portable, sling/solid seat/back,
patient weight capacity up to and including 300 pounds
Y
Capped rental
✽ K0821 Power wheelchair, group 2 standard, portable, captains chair, patient
weight capacity up to and including 300 pounds Y

Capped rental
✽ K0822 Power wheelchair, group 2 standard, sling/solid seat/back, patient
weight capacity up to and including 300 pounds Y

Capped rental
✽ K0823 Power wheelchair, group 2 standard, captains chair, patient weight
capacity up to and including 300 pounds Y

Capped rental
✽ K0824 Power wheelchair, group 2 heavy duty, sling/solid seat/back, patient
weight capacity 301 to 450 pounds Y

Capped rental
✽ K0825 Power wheelchair, group 2 heavy duty, captains chair, patient
weight capacity 301 to 450 pounds Y

Capped rental
✽ K0826 Power wheelchair, group 2 very heavy duty, sling/solid seat/back,
patient weight capacity 451 to 600 pounds Y

Capped rental
✽ K0827 Power wheelchair, group 2 very heavy duty, captains chair, patient
weight capacity 451 to 600 pounds Y

Capped rental
✽ K0828 Power wheelchair, group 2 extra heavy duty, sling/solid seat/back,
patient weight capacity 601 pounds or more Y
 Capped rental
✽ K0829 Power wheelchair, group 2 extra heavy duty, captains chair, patient
weight 601 pounds or more Y

Capped rental
✽ K0830 Power wheelchair, group 2 standard, seat elevator, sling/solid
seat/back, patient weight capacity up to and including 300 pounds
Y

Capped rental
✽ K0831 Power wheelchair, group 2 standard, seat elevator, captains chair,
patient weight capacity up to and including 300 pounds Y

✽ K0835 Power wheelchair, group 2 standard, single power option, sling/solid

seat/back, patient weight capacity up to and including 300 pounds
Y

Capped rental
✽ K0836 Power wheelchair, group 2 standard, single power option, captains
chair, patient weight capacity up to and including 300 pounds
Y

Capped rental
✽ K0837 Power wheelchair, group 2 heavy duty, single power option,
sling/solid seat/back, patient weight capacity 301 to 450 pounds
Y

Capped rental
✽ K0838 Power wheelchair, group 2 heavy duty, single power option,
captains chair, patient weight capacity 301 to 450 pounds
Y
Capped rental
✽ K0839 Power wheelchair, group 2 very heavy duty, single power option,
sling/solid seat/back, patient weight capacity 451 to 600 pounds
Y

Capped rental
✽ K0840 Power wheelchair, group 2 extra heavy duty, single power option,
sling/solid seat/back, patient weight capacity 601 pounds or more
Y

Capped rental
✽ K0841 Power wheelchair, group 2 standard, multiple power option,
sling/solid seat/back, patient weight capacity up to and including
300 pounds Y

Capped rental
✽ K0842 Power wheelchair, group 2 standard, multiple power option,
captains chair, patient weight capacity up to and including 300
pounds Y

Capped rental
✽ K0843 Power wheelchair, group 2 heavy duty, multiple power option,
sling/solid seat/back, patient weight capacity 301 to 450 pounds
Y

Capped rental
✽ K0848 Power wheelchair, group 3 standard, sling/solid seat/back, patient
weight capacity up to and including 300 pounds Y

Capped rental
✽ K0849 Power wheelchair, group 3 standard, captains chair, patient weight
capacity up to and including 300 pounds Y

Capped rental
✽ K0850 Power wheelchair, group 3 heavy duty, sling/solid seat/back, patient
weight capacity 301 to 450 pounds Y

Capped rental
✽ K0851 Power wheelchair, group 3 heavy duty, captains chair, patient
weight capacity 301 to 450 pounds Y

Capped rental
✽ K0852 Power wheelchair, group 3 very heavy duty, sling/solid seat/back,
patient weight capacity 451 to 600 pounds Y

Capped rental
✽ K0853 Power wheelchair, group 3 very heavy duty, captains chair, patient
weight capacity 451 to 600 pounds Y

Capped rental
✽ K0854 Power wheelchair, group 3 extra heavy duty, sling/solid seat/back,
patient weight capacity 601 pounds or more Y

Capped rental
✽ K0855 Power wheelchair, group 3 extra heavy duty, captains chair, patient
weight capacity 601 pounds or more Y

Capped rental
✽ K0856 Power wheelchair, group 3 standard, single power option, sling/solid
seat/back, patient weight capacity up to and including 300 pounds
Y

Capped rental
✽ K0857 Power wheelchair, group 3 standard, single power option, captains
 chair, patient weight capacity up to and including 300 pounds
Y

Capped rental
✽ K0858 Power wheelchair, group 3 heavy duty, single power option,
sling/solid seat/back, patient weight 301 to 450 pounds
Y
Capped rental
✽ K0859 Power wheelchair, group 3 heavy duty, single power option,
captains chair, patient weight capacity 301 to 450 pounds
Y
Capped rental
✽ K0860 Power wheelchair, group 3 very heavy duty, single power option,
sling/solid seat/back, patient weight capacity 451 to 600 pounds
Y

Capped rental
✽ K0861 Power wheelchair, group 3 standard, multiple power option,
sling/solid seat/back, patient weight capacity up to and including
300 pounds Y

Capped rental
✽ K0862 Power wheelchair, group 3 heavy duty, multiple power option,
sling/solid seat/back, patient weight capacity 301 to 450 pounds
Y

Capped rental
✽ K0863 Power wheelchair, group 3 very heavy duty, multiple power option,
sling/solid seat/back, patient weight capacity 451 to 600 pounds
Y

Capped rental
✽ K0864 Power wheelchair, group 3 extra heavy duty, multiple power option,
sling/solid seat/back, patient weight capacity 601 pounds or more
Y

Capped rental
✽ K0868 Power wheelchair, group 4 standard, sling/solid seat/back, patient
weight capacity up to and including 300 pounds Y

Capped rental
✽ K0869 Power wheelchair, group 4 standard, captains chair, patient weight
capacity up to and including 300 pounds Y

Capped rental
✽ K0870 Power wheelchair, group 4 heavy duty, sling/solid seat/back, patient
 weight capacity 301 to 450 pounds Y

Capped rental
✽ K0871 Power wheelchair, group 4 very heavy duty, sling/solid seat/back,
patient weight capacity 451 to 600 pounds Y

Capped rental
✽ K0877 Power wheelchair, group 4 standard, single power option, sling/solid
seat/back, patient weight capacity up to and including 300 pounds
Y

Capped rental
✽ K0878 Power wheelchair, group 4 standard, single power option, captains
chair, patient weight capacity up to and including 300 pounds
Y
Capped rental
✽ K0879 Power wheelchair, group 4 heavy duty, single power option,
sling/solid seat/back, patient weight capacity 301 to 450 pounds
Y

Capped rental
✽ K0880 Power wheelchair, group 4 very heavy duty, single power option,
sling/solid seat/back, patient weight 451 to 600 pounds Y

Capped rental
✽ K0884 Power wheelchair, group 4 standard, multiple power option,
sling/solid seat/back, patient weight capacity up to and including
300 pounds Y

Capped rental
✽ K0885 Power wheelchair, group 4 standard, multiple power option,
captains chair, patient weight capacity up to and including 300
pounds Y

Capped rental
✽ K0886 Power wheelchair, group 4 heavy duty, multiple power option,
sling/solid seat/back, patient weight capacity 301 to 450 pounds
Y

Capped rental
✽ K0890 Power wheelchair, group 5 pediatric, single power option,
sling/solid seat/back, patient weight capacity up to and including
125 pounds Y

Capped rental
✽ K0891 Power wheelchair, group 5 pediatric, multiple power option,
 sling/solid seat/back, patient weight capacity up to and including
125 pounds Y

Capped rental
✽ K0898 Power wheelchair, not otherwise classified Y

✽ K0899 Power mobility device, not coded by DME PDAC or does not meet
criteria Y

Customized DME: Other than Wheelchair

❂ K0900 Customized durable medical equipment, other than wheelchair
Y

Devices
✽ K1001 Electronic positional obstructive sleep apnea treatment, with sensor,
includes all components and accessories, any type Y

K1002 Cranial electrotherapy stimulation (CES) system, any type E1

✽ K1003 Whirlpool tub, walk-in, portable Y

✽ K1004 Low frequency ultrasonic diathermy treatment device for home use,
includes all components and accessories Y

✽ K1005 Disposable collection and storage bag for breast milk, any size, any
type, each Y

✽ K1006 Suction pump, home model, portable or stationary, electric, any

type, for use with external urine management system Y

✽ K1007 Bilateral hip, knee, ankle, foot device, powered, includes pelvic
component, single or double upright(s), knee joints any type, with or
without ankle joints any type, includes all components and
accessories, motors, microprocessors, sensors Y

✽ K1009 Speech volume modulation system, any type, including all

components and accessories Y

✽ K1013 Enema tube, with or without adapter, any type, replacement only,
each Y

✽ K1014 Addition, endoskeletal knee-shin system, 4 bar linkage or

multiaxial, fluid swing and stance phase control Y

✽ K1015 Foot, adductus positioning device, adjustable Y

✽ K1016 Transcutaneous electrical nerve stimulator for electrical stimulation

 of the trigeminal nerve Y

✽ K1017 Monthly supplies for use of device coded at K1016 Y

✽ K1018 External upper limb tremor stimulator of the peripheral nerves of the
wrist Y

✽ K1019 Replacement supplies and accessories for external upper limb

tremor stimulator of the peripheral nerves of the wrist Y

✽ K1020 Non-invasive vagus nerve stimulator Y

✽ K1021 Exsufflation belt, includes all supplies and accessories Y

✽ K1022 Addition to lower extremity prosthesis, endoskeletal, knee

disarticulation, above knee, hip disarticulation, positional rotation
unit, any type Y

✽ K1023 Distal transcutaneous electrical nerve stimulator, stimulates

peripheral nerves of the upper arm Y

✽ K1024 Non-pneumatic compression controller with sequential calibrated

gradient pressure Y

✽ K1025 Non-pneumatic sequential compression garment, full arm Y

✽ K1026 Mechanical allergen particle barrier/inhalation filter, cream, nasal,

topical Y

✽ K1027 Oral device/appliance used to reduce upper airway collapsibility,

without fixed mechanical hinge, custom fabricated, includes fitting
and adjustment Y

Self-administered test
▶ K1034 Provision of covid-19 test, nonprescription self-administered and
self-collected use, FDA approved, authorized or cleared, one test
count
Figure 19 (A) Flexible cervical collar. (B) Adjustable cervical collar.

ORTHOTICS & DEVICES (L0112-L4631)

NOTE: DMEPOS fee schedule https://www.cms.gov/Medicare/Medicare-Fee-for-
Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html

Cervical Orthotics
✽ L0112 Cranial cervical orthosis, congenital torticollis type, with or without
soft interface material, adjustable range of motion joint, custom
fabricated A

✽ L0113 Cranial cervical orthosis, torticollis type, with or without joint, with
or without soft interface material, prefabricated, includes fitting and
adjustment A

✽ L0120 Cervical, flexible, non-adjustable, prefabricated, off-the-shelf (foam

collar) A

Cervical orthoses including soft and rigid devices may be used as

nonoperative management for cervical trauma
✽ L0130 Cervical, flexible, thermoplastic collar, molded to patient
A
✽ L0140 Cervical, semi-rigid, adjustable (plastic collar) A

✽ L0150 Cervical, semi-rigid, adjustable molded chin cup (plastic collar with
mandibular/occipital piece) A

✽ L0160 Cervical, semi-rigid, wire frame occipital/mandibular support,

prefabricated, off-the-shelf A
 ✽ L0170 Cervical, collar, molded to patient model A

✽ L0172 Cervical, collar, semi-rigid thermoplastic foam, two-piece,

prefabricated, off-the-shelf A

✽ L0174 Cervical, collar, semi-rigid, thermoplastic foam, two piece with

thoracic extension, prefabricated, off-the-shelf A

Multiple Post Collar: Cervical

✽ L0180 Cervical, multiple post collar, occipital/mandibular supports,
adjustable A

✽ L0190 Cervical, multiple post collar, occipital/mandibular supports,

adjustable cervical bars (SOMI, Guilford, Taylor types)
A
✽ L0200 Cervical, multiple post collar, occipital/mandibular supports,
adjustable cervical bars, and thoracic extension A

Thoracic Rib Belt

✽ L0220 Thoracic, rib belt, custom fabricated A

Thoracic-Lumbar-Sacral Orthotics
✽ L0450 TLSO, flexible, provides trunk support, upper thoracic region,
produces intracavitary pressure to reduce load on the intervertebral
disks with rigid stays or panel(s), includes shoulder straps and
closures, prefabricated, off-the-shelf A

Used to immobilize specified area of spine, and is generally worn

under clothing
✽ L0452 TLSO, flexible, provides trunk support, upper thoracic region,
produces intracavitary pressure to reduce load on the intervertebral
disks with rigid stays or panel(s), includes shoulder straps and
closures, custom fabricated A
Figure 20 Thoracic-lumbar-sacral-orthosis (TLSO).

✽ L0454 TLSO flexible, provides trunk support, extends from sacrococcygeal

junction to above T-9 vertebra, restricts gross trunk motion in the
sagittal plane, produces intracavitary pressure to reduce load on the
intervertebral disks with rigid stays or panel(s), includes shoulder
straps and closures, prefabricated item that has been trimmed, bent,
molded, assembled, or otherwise customized to fit a specific patient
by an individual with expertise A

Used to immobilize specified areas of spine; and is generally

designed to be worn under clothing; not specifically designed for
patients in wheelchairs
✽ L0455 TLSO, flexible, provides trunk support, extends from
sacrococcygeal junction to above T-9 vertebra, restricts gross trunk
motion in the sagittal plane, produces intracavitary pressure to
reduce load on the intervertebral disks with rigid stays or panel(s),
includes shoulder straps and closures, prefabricated, off-the-shelf
A

✽ L0456 TLSO, flexible, provides trunk support, thoracic region, rigid

posterior panel and soft anterior apron, extends from the
sacrococcygeal junction and terminates just inferior to the scapular
spine, restricts gross trunk motion in the sagittal plane, produces
intracavitary pressure to reduce load on the intervertebral disks,
includes straps and closures, prefabricated item that has been
trimmed, bent, molded, assembled, or otherwise customized to fit a
specific patient by an individual with expertise A

✽ L0457 TLSO, flexible, provides trunk support, thoracic region, rigid

posterior panel and soft anterior apron, extends from the
sacrococcygeal junction and terminates just inferior to the scapular
 spine, restricts gross trunk motion in the sagittal plane, produces
intracavitary pressure to reduce load on the intervertebral disks,
includes straps and closures, prefabricated, off-the-shelf
A
✽ L0458 TLSO, triplanar control, modular segmented spinal system, two
rigid plastic shells, posterior extends from the sacrococcygeal
junction and terminates just inferior to the scapular spine, anterior
extends from the symphysis pubis to the xiphoid, soft liner, restricts
gross trunk motion in the sagittal, coronal, and transverse planes,
lateral strength is provided by overlapping plastic and stabilizing
closures, includes straps and closures, prefabricated, includes fitting
and adjustment A

To meet Medicare’s definition of body jacket, orthosis has to have

rigid plastic shell that circles trunk with overlapping edges and
stabilizing closures, and entire circumference of shell must be made
of same rigid material.
✽ L0460 TLSO, triplanar control, modular segmented spinal system, two
rigid plastic shells, posterior extends from the sacrococcygeal
junction and terminates just inferior to the scapular spine, anterior
extends from the symphysis pubis to the sternal notch, soft liner,
restricts gross trunk motion in the sagittal, coronal, and transverse
planes, lateral strength is provided by overlapping plastic and
stabilizing closures, includes straps and closures, prefabricated item
that has been trimmed, bent, molded, assembled, or otherwise
customized to fit a specific patient by an individual with expertise
A

✽ L0462 TLSO, triplanar control, modular segmented spinal system, three

rigid plastic shells, posterior extends from the sacrococcygeal
junction and terminates just inferior to the scapular spine, anterior
extends from the symphysis pubis to the sternal notch, soft liner,
restricts gross trunk motion in the sagittal, coronal, and transverse
planes, lateral strength is provided by overlapping plastic and
stabilizing closures, includes straps and closures, prefabricated,
includes fitting and adjustment A

✽ L0464 TLSO, triplanar control, modular segmented spinal system, four

rigid plastic shells, posterior extends from sacrococcygeal junction
and terminates just inferior to scapular spine, anterior extends from
symphysis pubis to the sternal notch, soft liner, restricts gross trunk
motion in sagittal, coronal, and transverse planes, lateral strength is
provided by overlapping plastic and stabilizing closures, includes
straps and closures, prefabricated, includes fitting and adjustment
 A

✽ L0466 TLSO, sagittal control, rigid posterior frame and flexible soft
anterior apron with straps, closures and padding, restricts gross
trunk motion in sagittal plane, produces intracavitary pressure to
reduce load on intervertebral disks, prefabricated item that has been
trimmed, bent, molded, assembled, or otherwise customized to fit a
specific patient by an individual with expertise A

✽ L0467 TLSO, sagittal control, rigid posterior frame and flexible soft
anterior apron with straps, closures and padding, restricts gross
trunk motion in sagittal plane, produces intracavitary pressure to
reduce load on intervertebral disks, prefabricated, off-the-shelf
A

✽ L0468 TLSO, sagittal-coronal control, rigid posterior frame and flexible

soft anterior apron with straps, closures and padding, extends from
sacrococcygeal junction over scapulae, lateral strength provided by
pelvic, thoracic, and lateral frame pieces, restricts gross trunk
motion in sagittal, and coronal planes, produces intracavitary
pressure to reduce load on intervertebral disks, prefabricated item
that has been trimmed, bent, molded, assembled, or otherwise
customized to fit a specific patient by an individual with expertise
A

✽ L0469 TLSO, sagittal-coronal control, rigid posterior frame and flexible

soft anterior apron with straps, closures and padding, extends from
sacrococcygeal junction over scapulae, lateral strength provided by
pelvic, thoracic, and lateral frame pieces, restricts gross trunk
motion in sagittal and coronal planes, produces intracavitary
pressure to reduce load on intervertebral disks, prefabricated, off-
the-shelf A

✽ L0470 TLSO, triplanar control, rigid posterior frame and flexible soft
anterior apron with straps, closures and padding, extends from
sacrococcygeal junction to scapula, lateral strength provided by
pelvic, thoracic, and lateral frame pieces, rotational strength
provided by subclavicular extensions, restricts gross trunk motion in
sagittal, coronal, and transverse planes, provides intracavitary
pressure to reduce load on the intervertebral disks, includes fitting
and shaping the frame, prefabricated, includes fitting and adjustment
A

✽ L0472 TLSO, triplanar control, hyperextension, rigid anterior and lateral

frame extends from symphysis pubis to sternal notch with two
anterior components (one pubic and one sternal), posterior and
 lateral pads with straps and closures, limits spinal flexion, restricts
gross trunk motion in sagittal, coronal, and transverse planes,
includes fitting and shaping the frame, prefabricated, includes fitting
and adjustment A

✽ L0480 TLSO, triplanar control, one piece rigid plastic shell without
interface liner, with multiple straps and closures, posterior extends
from sacrococcygeal junction and terminates just inferior to scapular
spine, anterior extends from symphysis pubis to sternal notch,
anterior or posterior opening, restricts gross trunk motion in sagittal,
coronal, and transverse planes, includes a carved plaster or CAD-
CAM model, custom fabricated A

Figure 21 Thoracic-lumbar-sacral orthosis (TLSO) Jewett flexion control.

✽ L0482 TLSO, triplanar control, one piece rigid plastic shell with interface
liner, multiple straps and closures, posterior extends from
sacrococcygeal junction and terminates just inferior to scapular
spine, anterior extends from symphysis pubis to sternal notch,
anterior or posterior opening, restricts gross trunk motion in sagittal,
coronal, and transverse planes, includes a carved plaster or CAD-
CAM model, custom fabricated A

✽ L0484 TLSO, triplanar control, two piece rigid plastic shell without
interface liner, with multiple straps and closures, posterior extends
from sacrococcygeal junction and terminates just inferior to scapular
spine, anterior extends from symphysis pubis to sternal notch,
lateral strength is enhanced by overlapping plastic, restricts gross
trunk motion in the sagittal, coronal, and transverse planes, includes
a carved plaster or CAD-CAM model, custom fabricated
 A
✽ L0486 TLSO, triplanar control, two piece rigid plastic shell with interface
liner, multiple straps and closures, posterior extends from
sacrococcygeal junction and terminates just inferior to scapular
spine, anterior extends from symphysis pubis to sternal notch,
lateral strength is enhanced by overlapping plastic, restricts gross
trunk motion in the sagittal, coronal, and transverse planes, includes
a carved plaster or CAD-CAM model, custom fabricated
A
✽ L0488 TLSO, triplanar control, one piece rigid plastic shell with interface
liner, multiple straps and closures, posterior extends from
sacrococcygeal junction and terminates just inferior to scapular
spine, anterior extends from symphysis pubis to sternal notch,
anterior or posterior opening, restricts gross trunk motion in sagittal,
coronal, and transverse planes, prefabricated, includes fitting and
adjustment A

✽ L0490 TLSO, sagittal-coronal control, one piece rigid plastic shell, with
overlapping reinforced anterior, with multiple straps and closures,
posterior extends from sacrococcygeal junction and terminates at or
before the T-9 vertebra, anterior extends from symphysis pubis to
xiphoid, anterior opening, restricts gross trunk motion in sagittal and
coronal planes, prefabricated, includes fitting and adjustment
A

✽ L0491 TLSO, sagittal-coronal control, modular segmented spinal system,

two rigid plastic shells, posterior extends from the sacrococcygeal
junction and terminates just inferior to the scapular spine, anterior
extends from the symphysis pubis to the xiphoid, soft liner, restricts
gross trunk motion in the sagittal and coronal planes, lateral strength
is provided by overlapping plastic and stabilizing closures, includes
straps and closures, prefabricated, includes fitting and adjustment
A

✽ L0492 TLSO, sagittal-coronal control, modular segmented spinal system,

three rigid plastic shells, posterior extends from the sacrococcygeal
junction and terminates just inferior to the scapular spine, anterior
extends from the symphysis pubis to the xiphoid, soft liner, restricts
gross trunk motion in the sagittal and coronal planes, lateral strength
is provided by overlapping plastic and stabilizing closures, includes
straps and closures, prefabricated, includes fitting and adjustment
A

Sacroilliac Orthotics
 ✽ L0621 Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces
motion about the sacroiliac joint, includes straps, closures, may
include pendulous abdomen design, prefabricated, off-the-shelf
A

✽ L0622 Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces

motion about the sacroiliac joint, includes straps, closures, may
include pendulous abdomen design, custom fabricated
A
Type of custom-fabricated device for which impression of
specific body part is made (e.g., by means of plaster cast, or CAD-
CAM [computer-aided design] technology); impression then used to
make specific patient model
✽ L0623 Sacroiliac orthosis, provides pelvicsacral 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, off-the-shelf
A
✽ L0624 Sacroiliac orthosis, provides pelvicsacral 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
A
Custom fitted

Lumbar Orthotics
✽ L0625 Lumbar orthosis, flexible, provides lumbar support, 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 pendulous abdomen design, shoulder straps,
stays, prefabricated, off-the-shelf A

✽ L0626 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 intervertebral discs,
includes straps, closures, may include padding, stays, shoulder
straps, pendulous abdomen design, prefabricated item that has been
trimmed, bent, molded, assembled, or otherwise customized to fit a
specific patient by an individual with expertise A

✽ L0627 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 item that has been
 trimmed, bent, molded, assembled, or otherwise customized to fit a
specific patient by an individual with expertise A

Lumbar-Sacral Orthotics
✽ L0628 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, off-the-shelf
A
✽ L0629 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, custom fabricated A

Custom fitted
✽ L0630 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
item that has been trimmed, bent, molded, assembled, or otherwise
customized to fit a specific patient by an individual with expertise
A

Figure 22 Lumbar-sacral orthosis.

✽ L0631 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 item that
has been trimmed, bent, molded, assembled, or otherwise
customized to fit a specific patient by an individual with expertise
A

✽ L0632 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
A

Custom fitted
✽ L0633 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 item that
has been trimmed, bent, molded, assembled, or otherwise
customized to fit a specific patient by an individual with expertise
A

✽ L0634 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/panel(s),
produces intracavitary pressure to reduce load on intervertebral
discs, includes straps, closures, may include padding, stays,
shoulder straps, pendulous abdomen design, custom fabricated
A

Custom fitted
✽ L0635 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/panel(s),
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 A

✽ L0636 Lumbar sacral orthosis, sagittal-coronal control, lumbar flexion,

rigid posterior frame/panels, 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 A

Custom fitted
✽ L0637 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 item that
has been trimmed, bent, molded, assembled, or otherwise
customized to fit a specific patient by an individual with expertise
A

✽ L0638 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
A

✽ L0639 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 xyphoid,
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 item that has
been trimmed, bent, molded, assembled, or otherwise customized to
fit a specific patient by an individual with expertise A

Characterized by rigid plastic shell that encircles trunk with

overlapping edges and stabilizing closures and provides high degree
of immobility
✽ L0640 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 xyphoid,
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
A
Custom fitted

Lumbar Orthotics
✽ L0641 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 intervertebral discs,
includes straps, closures, may include padding, stays, shoulder
straps, pendulous abdomen design, prefabricated, off-the-shelf
A

✽ L0642 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, off-the-shelf
A

Lumbar-Sacral Orthotics
✽ L0643 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,
off-the-shelf A

✽ L0648 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, off-the-
shelf A

✽ L0649 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, off-the-
shelf A

✽ L0650 Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior

and posterior frame/panel(s), posterior extends from sacrococcygeal
 junction to T-9 vertebra, lateral strength provided by rigid lateral
frame/panel(s), produces intracavitary pressure to reduce load on
intervertebral discs, includes straps, closures, may include padding,
shoulder straps, pendulous abdomen design, prefabricated, off-the-
shelf A

✽ L0651 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 xyphoid,
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, off-the-shelf
A

Cervical-Thoracic-Lumbar-Sacral
✽ L0700 Cervical-thoracic-lumbar-sacralorthoses (CTLSO), anterior-
posteriorlateral control, molded to patient model (Minerva type)
A

✽ L0710 CTLSO, anterior-posterior-lateralcontrol, molded to patient model,

with interface material (Minerva type) A

HALO Procedure
✽ L0810 HALO procedure, cervical halo incorporated into jacket vest
A

✽ L0820 HALO procedure, cervical halo incorporated into plaster body

jacket A

✽ L0830 HALO procedure, cervical halo incorporated into Milwaukee type

orthosis A

✽ L0859 Addition to HALO procedure, magnetic resonance image

compatible systems, rings and pins, any material A

✽ L0861 Addition to HALO procedure, replacement liner/interface material

A
Figure 23 Halo device.

Additions to Spinal Orthotics

NOTE: TLSO - Thoraci-lumbar-sacral orthoses/Spinal orthoses may be

prefabricated, prefitted, or custom fabricated. Conservative treatment for back
pain may include the use of spinal orthoses.
✽ L0970 TLSO, corset front A

✽ L0972 LSO, corset front A

✽ L0974 TLSO, full corset A

✽ L0976 LSO, full corset A

✽ L0978 Axillary crutch extension A

✽ L0980 Peroneal straps, prefabricated, off-the-shelf, pair A

✽ L0982 Stocking supporter grips, prefabricated, off-the-shelf, set of four (4)

A

Convenience item
✽ L0984 Protective body sock, prefabricated, off-the-shelf, each
A
Garment made of cloth or similar material that is worn under
spinal orthosis and is not primarily medical in nature
✽ L0999 Addition to spinal orthosis, not otherwise specified A

Orthotic Devices: Scoliosis Procedures

NOTE: Orthotic care of scoliosis differs from other orthotic care in that the
treatment is more dynamic in nature and uses ongoing continual modification of
the orthosis to the patient’s changing condition. This coding structure uses the
proper names, or eponyms, of the procedures because they have historic and
universal acceptance in the profession. It should be recognized that variations to
the basic procedures described by the founders/developers are accepted in
various medical and orthotic practices throughout the country. All procedures
include a model of patient when indicated.
✽ L1000 Cervical-thoracic-lumbar-sacral orthosis (CTLSO) (Milwaukee),
inclusive of furnishing initial orthosis, including model
A
✽ L1001 Cervical thoracic lumbar sacral orthosis, immobilizer, infant size,
prefabricated, includes fitting and adjustment A

Figure 24 Milwaukee CTLSO.

✽ L1005 Tension based scoliosis orthosis and accessory pads, includes fitting
and adjustment A

✽ L1010 Addition to cervical-thoracic-lumbarsacral orthosis (CTLSO) or

scoliosis orthosis, axilla sling A

✽ L1020 Addition to CTLSO or scoliosis orthosis, kyphosis pad

A
✽ L1025 Addition to CTLSO or scoliosis orthosis, kyphosis pad, floating
A

✽ L1030 Addition to CTLSO or scoliosis orthosis, lumbar bolster pad

A

✽ L1040 Addition to CTLSO or scoliosis orthosis, lumbar or lumbar rib pad

A

✽ L1050 Addition to CTLSO or scoliosis orthosis, sternal pad A

✽ L1060 Addition to CTLSO or scoliosis orthosis, thoracic pad

A
✽ L1070 Addition to CTLSO or scoliosis orthosis, trapezius sling
A
✽ L1080 Addition to CTLSO or scoliosis orthosis, outrigger A

✽ L1085 Addition to CTLSO or scoliosis orthosis, outrigger, bilateral with

 vertical extensions A

✽ L1090 Addition to CTLSO or scoliosis orthosis, lumbar sling

A
✽ L1100 Addition to CTLSO or scoliosis orthosis, ring flange, plastic or
leather A

✽ L1110 Addition to CTLSO or scoliosis orthosis, ring flange, plastic or

leather, molded to patient model A

✽ L1120 Addition to CTLSO, scoliosis orthosis, cover for upright, each

A

Thoracic-Lumbar-Sacral (Low Profile)

✽ L1200 Thoracic-lumbar-sacral-orthosis (TLSO), inclusive of furnishing
initial orthosis only A

✽ L1210 Addition to TLSO, (low profile), lateral thoracic extension

A
✽ L1220 Addition to TLSO, (low profile), anterior thoracic extension
A

✽ L1230 Addition to TLSO, (low profile), Milwaukee type superstructure

A

✽ L1240 Addition to TLSO, (low profile), lumbar derotation pad

A
✽ L1250 Addition to TLSO, (low profile), anterior ASIS pad A

✽ L1260 Addition to TLSO, (low profile), anterior thoracic derotation pad

A

✽ L1270 Addition to TLSO, (low profile), abdominal pad A

✽ L1280 Addition to TLSO, (low profile), rib gusset (elastic), each

A
✽ L1290 Addition to TLSO, (low profile), lateral trochanteric pad
A

Other Scoliosis Procedures

✽ L1300 Other scoliosis procedure, body jacket molded to patient model
A

✽ L1310 Other scoliosis procedure, postoperative body jacket A

✽ L1499 Spinal orthosis, not otherwise specified A

Orthotic Devices: Lower Limb (L1600-L3649)

NOTE: the procedures in L1600-L2999 are considered as base or basic procedures

and may be modified by listing procedure from the Additions Sections and
adding them to the base procedure.

Hip: Flexible
✽ L1600 Hip orthosis, abduction control of hip joints, flexible, frejka type
with cover, prefabricated item that has been trimmed, bent, molded,
assembled, or otherwise customized to fit a specific patient by an
individual with expertise A

✽ L1610 Hip orthosis, abduction control of hip joints, flexible, (frejka cover
only), prefabricated item that has been trimmed, bent, molded,
assembled, or otherwise customized to fit a specific patient by an
individual with expertise A

✽ L1620 Hip orthosis, abduction control of hip joints, flexible, (Pavlik

harness), prefabricated item that has been trimmed, bent, molded,
assembled, or otherwise customized to fit a specific patient by an
individual with expertise A

✽ L1630 Hip orthosis, abduction control of hip joints, semi-flexible (Von

Rosen type), custom-fabricated A

✽ L1640 Hip orthosis, abduction control of hip joints, static, pelvic band or
spreader bar, thigh cuffs, custom-fabricated A

✽ L1650 Hip orthosis, abduction control of hip joints, static, adjustable,

(Ilfled type), prefabricated, includes fitting and adjustment
A
✽ L1652 Hip orthosis, bilateral thigh cuffs with adjustable abductor spreader
bar, adult size, prefabricated, includes fitting and adjustment, any
type A

✽ L1660 Hip orthosis, abduction control of hip joints, static, plastic,

prefabricated, includes fitting and adjustment A

✽ L1680 Hip orthosis, abduction control of hip joints, dynamic, pelvic

control, adjustable hip motion control, thigh cuffs (Rancho hip
action type), custom fabrication A

✽ L1685 Hip orthosis, abduction control of hip joint, postoperative hip

abduction type, custom fabricated A

✽ L1686 Hip orthosis, abduction control of hip joint, postoperative hip

abduction type, prefabricated, includes fitting and adjustment
A

✽ L1690 Combination, bilateral, lumbo-sacral, hip, femur orthosis providing

adduction and internal rotation control, prefabricated, includes
 fitting and adjustment A

Figure 25 Thoracic-hip-knee-ankle orthosis (THKAO).

Legg Perthes
✽ L1700 Legg-Perthes orthosis (Toronto type), custom-fabricated
A
✽ L1710 Legg-Perthes orthosis (Newington type), custom-fabricated
A
✽ L1720 Legg-Perthes orthosis, trilateral (Tachdjian type), custom-fabricated
A

✽ L1730 Legg-Perthes orthosis (Scottish Rite type), custom-fabricated

A

✽ L1755 Legg-Perthes orthosis (Patten bottom type), custom-fabricated

A

Knee (KO)
✽ L1810 Knee orthosis, elastic with joints, prefabricated item that has been
trimmed, bent, molded, assembled, or otherwise customized to fit a
specific patient by an individual with expertise A

✽ L1812 Knee orthosis, elastic with joints, prefabricated, off-the-shelf

A

✽ L1820 Knee orthosis, elastic with condylar pads and joints, with or without
patellar control, prefabricated, includes fitting and adjustment
A
Figure 26 Hip orthosis.

Figure 27 Knee orthosis.

✽ L1830 Knee orthosis, immobilizer, canvas longitudinal, prefabricated, off-

the-shelf A

✽ L1831 Knee orthosis, locking knee joint(s), positional orthosis,

prefabricated, includes fitting and adjustment A

✽ L1832 Knee orthosis, adjustable knee joints (unicentric or polycentric),

positional orthosis, rigid support, prefabricated item that has been
trimmed, bent, molded, assembled, or otherwise customized to fit a
specific patient by an individual with expertise A

✽ L1833 Knee orthosis, adjustable knee joints (unicentric or polycentric),

positional orthosis, rigid support, prefabricated, off-the-shelf
A
✽ L1834 Knee orthosis, without knee joint, rigid, custom-fabricated
A
✽ L1836 Knee orthosis, rigid, without joint(s), includes soft interface
material, prefabricated, off-the-shelf A

✽ L1840 Knee orthosis, derotation, mediallateral, anterior cruciate ligament,

custom fabricated A

✽ L1843 Knee orthosis, single upright, thigh and calf, with adjustable flexion
and extension joint (unicentric or polycentric), medial-lateral and
rotation control, with or without varus/valgus adjustment,
prefabricated item that has been trimmed, bent, molded, assembled,
or otherwise customized to fit a specific patient by an individual
with expertise A

✽ L1844 Knee orthosis, single upright, thigh and calf, with adjustable flexion
and extension joint (unicentric or polycentric), medial-lateral and
rotation control, with or without varus/valgus adjustment, custom
fabricated A

✽ L1845 Knee orthosis, double upright, thigh and calf, with adjustable
flexion and extension joint (unicentric or polycentric), medial-lateral
and rotation control, with or without varus/valgus adjustment,
prefabricated item that has been trimmed, bent, molded, assembled,
or otherwise customized to fit a specific patient by an individual
with expertise A

✽ L1846 Knee orthrosis, double upright, thigh and calf, with adjustable
flexion and extension joint (unicentric or polycentric), medial-lateral
and rotation control, with or without varus/valgus adjustment,
custom fabricated A

✽ L1847 Knee orthosis, double upright with adjustable joint, with inflatable
air support chamber(s), prefabricated item that has been trimmed,
bent, molded, assembled, or otherwise customized to fit a specific
patient by an individual with expertise A

✽ L1848 Knee orthosis, double upright with adjustable joint, with inflatable
air support chamber(s), prefabricated, off-the-shelf A

✽ L1850 Knee orthosis, Swedish type, prefabricated, off-the-shelf

A
✽ L1851 Knee orthosis (KO), single upright, thigh and calf, with adjustable
flexion and extension joint (unicentric or polycentric), medial-lateral
and rotation control, with or without varus/valgus adjustment,
prefabricated, off-the-shelf A

✽ L1852 Knee orthosis (KO), double upright, thigh and calf, with adjustable
flexion and extension joint (unicentric or polycentric), medial-lateral
 and rotation control, with or without varus/valgus adjustment,
prefabricated, off-the-shelf A

✽ L1860 Knee orthosis, modification of supracondylar prosthetic socket,

custom fabricated (SK) A

Ankle-Foot (AFO)
✽ L1900 Ankle foot orthosis (AFO), spring wire, dorsiflexion assist calf
band, custom-fabricated A

✽ L1902 Ankle orthosis, ankle gauntlet or similiar, with or without joints,

prefabricated, off-the-shelf A

✽ L1904 Ankle orthosis, ankle gauntlet or similiar, with or without joints,

custom fabricated A

✽ L1906 Ankle foot orthosis, multiligamentus ankle support, prefabricated,

off-the-shelf A

✽ L1907 Ankle orthosis, supramalleolar with straps, with or without

interface/pads, custom fabricated A

✽ L1910 Ankle foot orthosis, posterior, single bar, clasp attachment to shoe
counter, prefabricated, includes fitting and adjustment
A
✽ L1920 Ankle foot orthosis, single upright with static or adjustable stop
(Phelps or Perlstein type), custom fabricated A

✽ L1930 Ankle foot orthosis, plastic or other material, prefabricated, includes

fitting and adjustment A

✽ L1932 Ankle foot orthosis, rigid anterior tibial section, total carbon fiber or
equal material, prefabricated, includes fitting and adjustment
A

✽ L1940 Ankle foot orthosis, plastic or other material, custom fabricated

A

✽ L1945 Ankle foot orthosis, plastic, rigid anterior tibial section (floor
reaction), custom fabricated A

✽ L1950 Ankle foot orthosis, spiral (Institute of Rehabilitation Medicine

type), plastic, custom fabricated A

✽ L1951 Ankle foot orthosis, spiral (Institute of Rehabilitative Medicine

type), plastic or other material, prefabricated, includes fitting and
adjustment A

✽ L1960 Ankle foot orthosis, posterior solid ankle, plastic, custom fabricated
A

✽ L1970 Ankle foot orthosis, plastic, with ankle joint, custom fabricated
 A

✽ L1971 Ankle foot orthosis, plastic or other material with ankle joint,
prefabricated, includes fitting and adjustment A

Figure 28 Ankle-foot orthosis (AFO).

✽ L1980 Ankle foot orthosis, single upright free plantar dorsiflexion, solid
stirrup, calf band/cuff (single bar ‘BK’ orthosis), custom fabricated
A

✽ L1990 Ankle foot orthosis, double upright free plantar dorsiflexion, solid
stirrup, calf band/cuff (double bar ‘BK’ orthosis), custom fabricated
A

Hip-Knee-Ankle-Foot (or Any Combination)

NOTE: L2000, L2020, and L2036 are base procedures to be used with any knee
joint. L2010 and L2030 are to be used only with no knee joint.
✽ L2000 Knee ankle foot orthosis, single upright, free knee, free ankle, solid
stirrup, thigh and calf bands/cuffs (single bar ‘AK’ orthosis),
custom-fabricated A

✽ L2005 Knee ankle foot orthosis, any material, single or double upright,
stance control, automatic lock and swing phase release, any type
activation; includes ankle joint, any type, custom fabricated
A

✽ L2006 Knee ankle foot device, any material, single or double upright,
swing and/or stance phase microprocessor control with adjustability,
includes all components (e.g., sensors, batteries, charger), any type
activation, with or without ankle joint(s), custom fabricated A
 ✽ L2010 Knee ankle foot orthosis, single upright, free ankle, solid stirrup,
thigh and calf bands/cuffs (single bar ‘AK’ orthosis), without knee
joint, custom-fabricated A

Figure 29 Knee-ankle-foot orthosis (KAFO).

✽ L2020 Knee ankle foot orthosis, double upright, free knee, free ankle, solid
stirrup, thigh and calf bands/cuffs (double bar ‘AK’ orthosis),
custom fabricated A

✽ L2030 Knee ankle foot orthosis, double upright, free ankle, solid stirrup,
thigh and calf bands/cuffs (double bar ‘AK’ orthosis), without knee
joint, custom fabricated A

✽ L2034 Knee ankle foot orthosis, full plastic, single upright, with or without
free motion knee, medial lateral rotation control, with or without
free motion ankle, custom fabricated A

✽ L2035 Knee ankle foot orthosis, full plastic, static (pediatric size), without
free motion ankle, prefabricated, includes fitting and adjustment
A

✽ L2036 Knee ankle foot orthosis, full plastic, double upright, with or
without free motion knee, with or without free motion ankle, custom
fabricated A

✽ L2037 Knee ankle foot orthosis, full plastic, single upright, with or without
free motion knee, with or without free motion ankle, custom
fabricated A

✽ L2038 Knee ankle foot orthosis, full plastic, with or without free motion
knee, multi-axis ankle, custom fabricated A

Torsion Control: Hip-Knee-Ankle-Foot (TLSO)

 ✽ L2040 Hip knee ankle foot orthosis, torsion control, bilateral rotation
straps, pelvic band/belt, custom fabricated A

Figure 30 Hip-knee-ankle-foot orthosis (HKAFO).

✽ L2050 Hip knee ankle foot orthosis, torsion control, bilateral torsion cables,
hip joint, pelvic band/belt, custom fabricated A

✽ L2060 Hip knee ankle foot orthosis, torsion control, bilateral torsion cables,
ball bearing hip joint, pelvic band/belt, custom fabricated
A
✽ L2070 Hip knee ankle foot orthosis, torsion control, unilateral rotation
straps, pelvic band/belt, custom fabricated A

✽ L2080 Hip knee ankle foot orthosis, torsion control, unilateral torsion
cable, hip joint, pelvic band/belt, custom fabricated A

✽ L2090 Hip knee ankle foot orthosis, torsion control, unilateral torsion
cable, ball bearing hip joint, pelvic band/belt, custom fabricated
A

Fracture Orthotics: Ankle-Foot and Knee-Ankle-Foot

✽ L2106 Ankle foot orthosis, fracture orthosis, tibial fracture cast orthosis,
thermoplastic type casting material, custom fabricated
A
✽ L2108 Ankle foot orthosis, fracture orthosis, tibial fracture cast orthosis,
custom fabricated A

✽ L2112 Ankle foot orthosis, fracture orthosis, tibial fracture orthosis, soft,
prefabricated, includes fitting and adjustment A

✽ L2114 Ankle foot orthosis, fracture orthosis, tibial fracture orthosis, semi-
rigid, prefabricated, includes fitting and adjustment A
 ✽ L2116 Ankle foot orthosis, fracture orthosis, tibial fracture orthosis, rigid,
prefabricated, includes fitting and adjustment A

✽ L2126 Knee ankle foot orthosis, fracture orthosis, femoral fracture cast
orthosis, thermoplastic type casting material, custom fabricated
A

✽ L2128 Knee ankle foot orthosis, fracture orthosis, femoral fracture cast
orthosis, custom fabricated A

✽ L2132 Knee ankle foot orthosis, femoral fracture cast orthosis, soft,
prefabricated, includes fitting and adjustment A

✽ L2134 Knee ankle foot orthosis, femoral fracture cast orthosis, semi-rigid,
prefabricated, includes fitting and adjustment A

✽ L2136 Knee ankle foot orthosis, fracture orthosis, femoral fracture cast
orthosis, rigid, prefabricated, includes fitting and adjustment
A

Additions to Fracture Orthotics

✽ L2180 Addition to lower extremity fracture orthosis, plastic shoe insert
with ankle joints A

✽ L2182 Addition to lower extremity fracture orthosis, drop lock knee joint
A

✽ L2184 Addition to lower extremity fracture orthosis, limited motion knee

joint A

✽ L2186 Addition to lower extremity fracture orthosis, adjustable motion

knee joint, Lerman type A

✽ L2188 Addition to lower extremity fracture orthosis, quadrilateral brim

A

✽ L2190 Addition to lower extremity fracture orthosis, waist belt

A
✽ L2192 Addition to lower extremity fracture orthosis, hip joint, pelvic band,
thigh flange, and pelvic belt A

Additions to Lower Extremity Orthotics

✽ L2200 Addition to lower extremity, limited ankle motion, each joint
A

✽ L2210 Addition to lower extremity, dorsiflexion assist (plantar flexion

resist), each joint A

✽ L2220 Addition to lower extremity, dorsiflexion and plantar flexion

assist/resist, each joint A
✽ L2230 Addition to lower extremity, split flat caliper stirrups and plate
attachment A

✽ L2232 Addition to lower extremity orthosis, rocker bottom for total contact
ankle foot orthosis, for custom fabricated orthosis only
A
✽ L2240 Addition to lower extremity, round caliper and plate attachment
A

✽ L2250 Addition to lower extremity, foot plate, molded to patient model,

stirrup attachment A

✽ L2260 Addition to lower extremity, reinforced solid stirrup (Scott-Craig

type) A

✽ L2265 Addition to lower extremity, long tongue stirrup A

✽ L2270 Addition to lower extremity, varus/valgus correction (‘T’) strap,

padded/lined or malleolus pad A

✽ L2275 Addition to lower extremity, varus/valgus correction, plastic

modification, padded/lined A

✽ L2280 Addition to lower extremity, molded inner boot A

✽ L2300 Addition to lower extremity, abduction bar (bilateral hip

involvement), jointed, adjustable A

✽ L2310 Addition to lower extremity, abduction bar-straight A

✽ L2320 Addition to lower extremity, nonmolded lacer, for custom fabricated

orthosis only A

✽ L2330 Addition to lower extremity, lacer molded to patient model, for

custom fabricated orthosis only A

Used whether closure is lacer or Velcro

✽ L2335 Addition to lower extremity, anterior swing band A

✽ L2340 Addition to lower extremity, pre-tibial shell, molded to patient

model A

✽ L2350 Addition to lower extremity, prosthetic type (BK) socket, molded to

patient model, (used for ‘PTB’ and ‘AFO’ orthoses) A

✽ L2360 Addition to lower extremity, extended steel shank A

✽ L2370 Addition to lower extremity, Patten bottom A

✽ L2375 Addition to lower extremity, torsion control, ankle joint and half
solid stirrup A

✽ L2380 Addition to lower extremity, torsion control, straight knee joint,

each joint A
 ✽ L2385 Addition to lower extremity, straight knee joint, heavy duty, each
joint A

✽ L2387 Addition to lower extremity, polycentric knee joint, for custom

fabricated knee ankle foot orthosis, each joint A

✽ L2390 Addition to lower extremity, offset knee joint, each joint A

✽ L2395 Addition to lower extremity, offset knee joint, heavy duty, each joint
A

✽ L2397 Addition to lower extremity orthosis, suspension sleeve A

Additions to Straight Knee or Offset Knee Joints

✽ L2405 Addition to knee joint, drop lock, each A

✽ L2415 Addition to knee lock with integrated release mechanism (bail,

cable, or equal), any material, each joint A

✽ L2425 Addition to knee joint, disc or dial lock for adjustable knee flexion,
each joint A

✽ L2430 Addition to knee joint, ratchet lock for active and progressive knee
extension, each joint A

✽ L2492 Addition to knee joint, lift loop for drop lock ring A

Additions to Thigh/Weight Bearing Gluteal/Ischial Weight Bearing

✽ L2500 Addition to lower extremity, thigh/weight bearing, gluteal/ischial
weight bearing, ring A

✽ L2510 Addition to lower extremity, thigh/weight bearing, quadri-lateral

brim, molded to patient model A

✽ L2520 Addition to lower extremity, thigh/weight bearing, quadri-lateral

brim, custom fitted A

✽ L2525 Addition to lower extremity, thigh/weight bearing, ischial

containment/narrow M-L brim molded to patient model
A
✽ L2526 Addition to lower extremity, thigh/weight bearing, ischial
containment/narrow M-L brim, custom fitted A

✽ L2530 Addition to lower extremity, thigh/weight bearing, lacer, nonmolded

A

✽ L2540 Addition to lower extremity, thigh/weight bearing, lacer, molded to

patient model A

✽ L2550 Addition to lower extremity, thigh/weight bearing, high roll cuff

A
Additions to Pelvic and Thoracic Control
✽ L2570 Addition to lower extremity, pelvic control, hip joint, Clevis type
two position joint, each A

✽ L2580 Addition to lower extremity, pelvic control, pelvic sling

A
✽ L2600 Addition to lower extremity, pelvic control, hip joint, Clevis type, or
thrust bearing, free, each A

✽ L2610 Addition to lower extremity, pelvic control, hip joint, Clevis or

thrust bearing, lock, each A

✽ L2620 Addition to lower extremity, pelvic control, hip joint, heavy duty,
each A

✽ L2622 Addition to lower extremity, pelvic control, hip joint, adjustable

flexion, each A

✽ L2624 Addition to lower extremity, pelvic control, hip joint, adjustable

flexion, extension, abduction control, each A

✽ L2627 Addition to lower extremity, pelvic control, plastic, molded to

patient model, reciprocating hip joint and cables A

✽ L2628 Addition to lower extremity, pelvic control, metal frame,

reciprocating hip joint and cables A

✽ L2630 Addition to lower extremity, pelvic control, band and belt, unilateral
A

✽ L2640 Addition to lower extremity, pelvic control, band and belt, bilateral
A

✽ L2650 Addition to lower extremity, pelvic and thoracic control, gluteal pad,
each A

✽ L2660 Addition to lower extremity, thoracic control, thoracic band

A

✽ L2670 Addition to lower extremity, thoracic control, paraspinal uprights

A

✽ L2680 Addition to lower extremity, thoracic control, lateral support

uprights A

General Additions
✽ L2750 Addition to lower extremity orthosis, plating chrome or nickel, per
bar A

✽ L2755 Addition to lower extremity orthosis, high strength, lightweight

material, all hybrid lamination/prepreg composite, per segment, for
 custom fabricated orthosis only A

✽ L2760 Addition to lower extremity orthosis, extension, per extension, per

bar (for lineal adjustment for growth) A

✽ L2768 Orthotic side bar disconnect device, per bar A

✽ L2780 Addition to lower extremity orthosis, non-corrosive finish, per bar

A

✽ L2785 Addition to lower extremity orthosis, drop lock retainer, each

A
✽ L2795 Addition to lower extremity orthosis, knee control, full kneecap
A

✽ L2800 Addition to lower extremity orthosis, knee control, knee cap, medial
or lateral pull, for use with custom fabricated orthosis only
A
✽ L2810 Addition to lower extremity orthosis, knee control, condylar pad
A

✽ L2820 Addition to lower extremity orthosis, soft interface for molded

plastic, below knee section A

Only report if soft interface provided, either leather or other material

✽ L2830 Addition to lower extremity orthosis, soft interface for molded
plastic, above knee section A

✽ L2840 Addition to lower extremity orthosis, tibial length sock, fracture or

equal, each A

✽ L2850 Addition to lower extremity orthosis, femoral length sock, fracture

or equal, each A

L2861 Addition to lower extremity joint, knee or ankle, concentric

adjustable torsion style mechanism for custom fabricated orthotics
only, each E1

✽ L2999 Lower extremity orthoses, not otherwise specified A

Figure 31 Foot inserts.

Foot (Orthopedic Shoes) (L3000-L3649)

Inserts
❂ L3000 Foot, insert, removable, molded to patient model, ‘UCB’ type,
Berkeley shell, each A

If both feet casted and supplied with an orthosis, bill L3000-LT and
L3000-RT
IOM: 100-02, 15, 290
❂ L3001 Foot, insert, removable, molded to patient model, Spenco, each
A

IOM: 100-02, 15, 290

❂ L3002 Foot, insert, removable, molded to patient model, Plastazote or
equal, each A

IOM: 100-02, 15, 290

❂ L3003 Foot, insert, removable, molded to patient model, silicone gel, each
A

IOM: 100-02, 15, 290

❂ L3010 Foot, insert, removable, molded to patient model, longitudinal arch
support, each A

IOM: 100-02, 15, 290

❂ L3020 Foot, insert, removable, molded to patient model,
longitudinal/metatarsal support, each A

IOM: 100-02, 15, 290

❂ L3030 Foot, insert, removable, formed to patient foot, each A

IOM: 100-02, 15, 290

✽ L3031 Foot, insert/plate, removable, addition to lower extremity orthosis,
high strength, lightweight material, all hybrid lamination/prepreg
composite, each A

Figure 32 Arch support.

Arch Support, Removable, Premolded

 ❂ L3040 Foot, arch support, removable, premolded, longitudinal, each
A

IOM: 100-02, 15, 290

❂ L3050 Foot, arch support, removable, premolded, metatarsal, each
A
IOM: 100-02, 15, 290
❂ L3060 Foot, arch support, removable, premolded, longitudinal/metatarsal,
each A

IOM: 100-02, 15, 290

Arch Support, Non-removable, Attached to Shoe

❂ L3070 Foot, arch support, non-removable attached to shoe, longitudinal,
each A

IOM: 100-02, 15, 290

❂ L3080 Foot, arch support, non-removable attached to shoe, metatarsal, each
A

IOM: 100-02, 15, 290

❂ L3090 Foot, arch support, non-removable attached to shoe,
longitudinal/metatarsal, each A

IOM: 100-02, 15, 290

❂ L3100 Hallus-valgus night dynamic splint, prefabricated, off-the-shelf
A

IOM: 100-02, 15, 290

Figure 33 Hallux valgus splint.

Abduction and Rotation Bars

❂ L3140 Foot, abduction rotation bar, including shoes A

IOM: 100-02, 15, 290

❂ L3150 Foot, abduction rotation bar, without shoes A

IOM: 100-02, 15, 290

 ✽ L3160 Foot, adjustable shoe-styled positioning device A

❂ L3170 Foot, plastic, silicone or equal, heel stabilizer, prefabricated, off-the-

shelf, each A

IOM: 100-02, 15, 290

Orthopedic Footwear
❂ L3201 Orthopedic shoe, oxford with supinator or pronator, infant A

IOM: 100-02, 15, 290

❂ L3202 Orthopedic shoe, oxford with supinator or pronator, child A

IOM: 100-02, 15, 290

❂ L3203 Orthopedic shoe, oxford with supinator or pronator, junior A

IOM: 100-02, 15, 290

❂ L3204 Orthopedic shoe, hightop with supinator or pronator, infant A

IOM: 100-02, 15, 290

❂ L3206 Orthopedic shoe, hightop with supinator or pronator, child A

IOM: 100-02, 15, 290

❂ L3207 Orthopedic shoe, hightop with supinator or pronator, junior A

IOM: 100-02, 15, 290

❂ L3208 Surgical boot, infant, each A

IOM: 100-02, 15, 100

Figure 34 Molded custom shoe.

❂ L3209 Surgical boot, each, child A

IOM: 100-02, 15, 100

❂ L3211 Surgical boot, each, junior A

IOM: 100-02, 15, 100

❂ L3212 Benesch boot, pair, infant A

IOM: 100-02, 15, 100

❂ L3213 Benesch boot, pair, child A

IOM: 100-02, 15, 100

❂ L3214 Benesch boot, pair, junior A

IOM: 100-02, 15, 100

L3215 Orthopedic footwear, ladies’ shoe, oxford, each ♀ E1

Medicare Statute 1862a8

L3216 Orthopedic footwear, ladies’ shoe, depth inlay, each ♀ E1

Medicare Statute 1862a8

L3217 Orthopedic footwear, ladies’ shoe, hightop, depth inlay, each
♀ E1

Medicare Statute 1862a8

L3219 Orthopedic footwear, men’s shoe, oxford, each ♂ E1

Medicare Statute 1862a8

L3221 Orthopedic footwear, men’s shoe, depth inlay, each ♂ E1

Medicare Statute 1862a8

L3222 Orthopedic footwear, men’s shoe, hightop, depth inlay, each
♂ E1

Medicare Statute 1862a8

❂ L3224 Orthopedic footwear, ladies’ shoe, oxford, used as an integral part of
a brace (orthosis) ♀ A

IOM: 100-02, 15, 290

❂ L3225 Orthopedic footwear, men’s shoe, oxford, used as an integral part of
a brace (orthosis) ♂ A

IOM: 100-02, 15, 290

❂ L3230 Orthopedic footwear, custom shoe, depth inlay, each A

IOM: 100-02, 15, 290

❂ L3250 Orthopedic footwear, custom molded shoe, removable inner mold,
prosthetic shoe, each A

IOM: 100-02, 15, 290

❂ L3251 Foot, shoe molded to patient model, silicone shoe, each A

IOM: 100-02, 15, 290

❂ L3252 Foot, shoe molded to patient model, Plastazote (or similar), custom
fabricated, each A

IOM: 100-02, 15, 290

❂ L3253 Foot, molded shoe Plastazote (or similar), custom fitted, each
 A
IOM: 100-02, 15, 290
❂ L3254 Non-standard size or width A

IOM: 100-02, 15, 290

❂ L3255 Non-standard size or length A

IOM: 100-02, 15, 290

❂ L3257 Orthopedic footwear, additional charge for split size A

IOM: 100-02, 15, 290

❂ L3260 Surgical boot/shoe, each E1

IOM: 100-02, 15, 100

✽ L3265 Plastazote sandal, each A

Shoe Lifts
❂ L3300 Lift, elevation, heel, tapered to metatarsals, per inch A

IOM: 100-02, 15, 290

❂ L3310 Lift, elevation, heel and sole, Neoprene, per inch A

IOM: 100-02, 15, 290

❂ L3320 Lift, elevation, heel and sole, cork, per inch A

IOM: 100-02, 15, 290

❂ L3330 Lift, elevation, metal extension (skate) A

IOM: 100-02, 15, 290

❂ L3332 Lift, elevation, inside shoe, tapered, up to one-half inch
A
IOM: 100-02, 15, 290
❂ L3334 Lift, elevation, heel, per inch A

IOM: 100-02, 15, 290

Shoe Wedges
❂ L3340 Heel wedge, SACH A

IOM: 100-02, 15, 290

❂ L3350 Heel wedge A

IOM: 100-02, 15, 290

❂ L3360 Sole wedge, outside sole A

IOM: 100-02, 15, 290

❂ L3370 Sole wedge, between sole A
 IOM: 100-02, 15, 290
❂ L3380 Clubfoot wedge A

IOM: 100-02, 15, 290

❂ L3390 Outflare wedge A

IOM: 100-02, 15, 290

❂ L3400 Metatarsal bar wedge, rocker A

IOM: 100-02, 15, 290

❂ L3410 Metatarsal bar wedge, between sole A

IOM: 100-02, 15, 290

❂ L3420 Full sole and heel wedge, between sole A

IOM: 100-02, 15, 290

Shoe Heels
❂ L3430 Heel, counter, plastic reinforced A

IOM: 100-02, 15, 290

❂ L3440 Heel, counter, leather reinforced A

IOM: 100-02, 15, 290

❂ L3450 Heel, SACH cushion type A

IOM: 100-02, 15, 290

❂ L3455 Heel, new leather, standard A

IOM: 100-02, 15, 290

❂ L3460 Heel, new rubber, standard A

IOM: 100-02, 15, 290

❂ L3465 Heel, Thomas with wedge A

IOM: 100-02, 15, 290

❂ L3470 Heel, Thomas extended to ball A

IOM: 100-02, 15, 290

❂ L3480 Heel, pad and depression for spur A

IOM: 100-02, 15, 290

❂ L3485 Heel, pad, removable for spur A

IOM: 100-02, 15, 290

Orthopedic Shoe Additions: Other

❂ L3500 Orthopedic shoe addition, insole, leather A
 IOM: 100-02, 15, 290
❂ L3510 Orthopedic shoe addition, insole, rubber A

IOM: 100-02, 15, 290

❂ L3520 Orthopedic shoe addition, insole, felt covered with leather
A
IOM: 100-02, 15, 290
❂ L3530 Orthopedic shoe addition, sole, half A

IOM: 100-02, 15, 290

❂ L3540 Orthopedic shoe addition, sole, full A

IOM: 100-02, 15, 290

❂ L3550 Orthopedic shoe addition, toe tap standard A

IOM: 100-02, 15, 290

❂ L3560 Orthopedic shoe addition, toe tap, horseshoe A

IOM: 100-02, 15, 290

❂ L3570 Orthopedic shoe addition, special extension to instep (leather with
eyelets) A

IOM: 100-02, 15, 290

❂ L3580 Orthopedic shoe addition, convert instep to Velcro closure
A
IOM: 100-02, 15, 290
❂ L3590 Orthopedic shoe addition, convert firm shoe counter to soft counter
A

IOM: 100-02, 15, 290

❂ L3595 Orthopedic shoe addition, March bar A

IOM: 100-02, 15, 290

Transfer or Replacement
❂ L3600 Transfer of an orthosis from one shoe to another, caliper plate,
existing A

IOM: 100-02, 15, 290

❂ L3610 Transfer of an orthosis from one shoe to another, caliper plate, new
A

IOM: 100-02, 15, 290

❂ L3620 Transfer of an orthosis from one shoe to another, solid stirrup,
existing A

IOM: 100-02, 15, 290

 ❂ L3630 Transfer of an orthosis from one shoe to another, solid stirrup, new
A

IOM: 100-02, 15, 290

❂ L3640 Transfer of an orthosis from one shoe to another, Dennis Browne
splint (Riveton), both shoes A

IOM: 100-02, 15, 290

❂ L3649 Orthopedic shoe, modification, addition or transfer, not otherwise
specified A

IOM: 100-02, 15, 290

Orthotic Devices: Upper Limb

NOTE: The procedures in this section are considered as base or basic procedures
and may be modified by listing procedures from the Additions section and
adding them to the base procedure.

Shoulder
✽ L3650 Shoulder orthosis, figure of eight design abduction restrainer,
prefabricated, off-the-shelf A

✽ L3660 Shoulder orthosis, figure of eight design abduction restrainer, canvas

and webbing, prefabricated, off-the-shelf A

✽ L3670 Shoulder orthosis, acromio/clavicular (canvas and webbing type),

prefabricated, off-the-shelf A

✽ L3671 Shoulder orthosis, shoulder joint design, without joints, may include
soft interface, straps, custom fabricated, includes fitting and
adjustment A

✽ L3674 Shoulder orthosis, abduction positioning (airplane design), thoracic

component and support bar, with or without nontorsion
joint/turnbuckle, may include soft interface, straps, custom
fabricated, includes fitting and adjustment A

✽ L3675 Shoulder orthosis, vest type abduction restrainer, canvas webbing

type or equal, prefabricated, off-the-shelf A

❂ L3677 Shoulder orthosis, shoulder joint design, without joints, may include
soft interface, straps, prefabricated item that has been trimmed, bent,
molded, assembled, or otherwise customized to fit a specific patient
by an individual with expertise A

✽ L3678 Shoulder orthosis, shoulder joint design, without joints, may include
soft interface, straps, prefabricated, off-the-shelf A
Figure 35 Elbow orthoses.

Elbow
✽ L3702 Elbow orthosis, without joints, may include soft interface, straps,
custom fabricated, includes fitting and adjustment A

✽ L3710 Elbow orthosis, elastic with metal joints, prefabricated, off-the-shelf

A

✽ L3720 Elbow orthosis, double upright with forearm/arm cuffs, free motion,
custom fabricated A

✽ L3730 Elbow orthosis, double upright with forearm/arm cuffs,

extension/flexion assist, custom fabricated A

✽ L3740 Elbow orthosis, double upright with forearm/arm cuffs, adjustable

position lock with active control, custom fabricated A

✽ L3760 Elbow orthosis (EO), with adjustable position locking joint(s),

prefabricated, item that has been trimmed, bent, molded, assembled,
or otherwise customized to fit a specific patient by an individual
with expertise A

✽ L3761 Elbow orthosis (EO), with adjustable position locking joint(s),

prefabricated, off-the-shelf A

✽ L3762 Elbow orthosis, rigid, without joints, includes soft interface

material, prefabricated, off-the-shelf A

✽ L3763 Elbow wrist hand orthosis, rigid, without joints, may include soft
interface, straps, custom fabricated, includes fitting and adjustment
A

✽ L3764 Elbow wrist hand orthosis, includes one or more nontorsion joints,
elastic bands, turnbuckles, may include soft interface, straps, custom
fabricated, includes fitting and adjustment A

✽ L3765 Elbow wrist hand finger orthosis, rigid, without joints, may include
soft interface, straps, custom fabricated, includes fitting and
adjustment A

✽ L3766 Elbow wrist hand finger orthosis, includes one or more nontorsion
joints, elastic bands, turnbuckles, may include soft interface, straps,
custom fabricated, includes fitting and adjustment A
Wrist-Hand-Finger Orthosis (WHFO)
✽ L3806 Wrist hand finger orthosis, includes one or more nontorsion joint(s),
turnbuckles, elastic bands/springs, may include soft interface
material, straps, custom fabricated, includes fitting and adjustment
A

✽ L3807 Wrist hand finger orthosis, without joint(s), prefabricated item that
has been trimmed, bent, molded, assembled, or otherwise
customized to fit a specific patient by an individual with expertise
A

✽ L3808 Wrist hand finger orthosis, rigid without joints, may include soft
interface material; straps, custom fabricated, includes fitting and
adjustment A

✽ L3809 Wrist hand finger orthosis, without joint(s), prefabricated, off-the-

shelf, any type A

L3891 Addition to upper extremity joint, wrist or elbow, concentric

adjustable torsion style mechanism for custom fabricated orthotics
only, each E1

✽ L3900 Wrist hand finger orthosis, dynamic flexor hinge, reciprocal wrist
extension/flexion, finger flexion/extension, wrist or finger driven,
custom fabricated A

✽ L3901 Wrist hand finger orthosis, dynamic flexor hinge, reciprocal wrist
extension/flexion, finger flexion/extension, cable driven, custom
fabricated A

✽ L3904 Wrist hand finger orthosis, external powered, electric, custom

fabricated A

Other Upper Extremity Orthotics

✽ L3905 Wrist hand orthosis, includes one or more nontorsion joints, elastic
bands, turnbuckles, may include soft interface, straps, custom
fabricated, includes fitting and adjustment A

✽ L3906 Wrist hand orthosis, without joints, may include soft interface,
straps, custom fabricated, includes fitting and adjustment
A
✽ L3908 Wrist hand orthosis, wrist extension control cock-up, non-molded,
prefabricated, off-the-shelf A

✽ L3912 Hand finger orthosis (HFO), flexion glove with elastic finger
control, prefabricated, off-the-shelf A

✽ L3913 Hand finger orthosis, without joints, may include soft interface,
 straps, custom fabricated, includes fitting and adjustment
A
✽ L3915 Wrist hand orthosis, includes one or more nontorsion joint(s), elastic
bands, turnbuckles, may include soft interface, straps, prefabricated
item that has been trimmed, bent, molded, assembled, or otherwise
customized to fit a specific patient by an individual with expertise
A

✽ L3916 Wrist hand orthosis, includes one or more nontorsion joint(s), elastic
bands, turnbuckles, may include soft interface, straps, prefabricated,
off-the-shelf A

✽ L3917 Hand orthosis, metacarpal fracture orthosis, prefabricated item that

has been trimmed, bent, molded, assembled, or otherwise
customized to fit a specific patient by an individual with expertise
A

✽ L3918 Hand orthosis, metacarpal fracture orthosis, prefabricated, off-the-

shelf A

✽ L3919 Hand orthosis, without joints, may include soft interface, straps,
custom fabricated, includes fitting and adjustment A

✽ L3921 Hand finger orthosis, includes one or more nontorsion joints, elastic
bands, turnbuckles, may include soft interface, straps, custom
fabricated, includes fitting and adjustment A

✽ L3923 Hand finger orthosis, without joints, may include soft interface,
straps, prefabricated item that has been trimmed, bent, molded,
assembled, or otherwise customized to fit a specific patient by an
individual with expertise A

✽ L3924 Hand finger orthosis, without joints, may include soft interface,
straps, prefabricated, off-the-shelf A

✽ L3925 Finger orthosis, proximal interphalangeal (PIP)/distal

interphalangeal (DIP), non torsion joint/spring, extension/flexion,
may include soft interface material, prefabricated, off-the-shelf
A

✽ L3927 Finger orthosis, proximal interphalangeal (PIP)/distal

interphalangeal (DIP), without joint/spring, extension/flexion (e.g.,
static or ring type), may include soft interface material,
prefabricated, off-the-shelf A

✽ L3929 Hand finger orthosis, includes one or more nontorsion joint(s),

turnbuckles, elastic bands/springs, may include soft interface
material, straps, prefabricated item that has been trimmed, bent,
molded, assembled, or otherwise customized to fit a specific patient
 by an individual with expertise A

✽ L3930 Hand finger orthosis, includes one or more nontorsion joint(s),

turnbuckles, elastic bands/springs, may include soft interface
material, straps, prefabricated, off-the-shelf A

✽ L3931 Wrist hand finger orthosis, includes one or more nontorsion joint(s),
turnbuckles, elastic bands/springs, may include soft interface
material, straps, prefabricated, includes fitting and adjustment
A

✽ L3933 Finger orthosis, without joints, may include soft interface, custom
fabricated, includes fitting and adjustment A

✽ L3935 Finger orthosis, nontorsion joint, may include soft interface, custom
fabricated, includes fitting and adjustment A

✽ L3956 Addition of joint to upper extremity orthosis, any material, per joint
A
Shoulder-Elbow-Wrist-Hand Orthotics (SEWHO) (L3960-L3973)
✽ L3960 Shoulder elbow wrist hand orthosis, abduction positioning, airplane
design, prefabricated, includes fitting and adjustment A

✽ L3961 Shoulder elbow wrist hand orthosis, shoulder cap design, without
joints, may include soft interface, straps, custom fabricated, includes
fitting and adjustment A

✽ L3962 Shoulder elbow wrist hand orthosis, abduction positioning, Erb’s

palsy design, prefabricated, includes fitting and adjustment
A
✽ L3967 Shoulder elbow wrist hand orthosis, abduction positioning (airplane
design), thoracic component and support bar, without joints, may
include soft interface, straps, custom fabricated, includes fitting and
adjustment A

✽ L3971 Shoulder elbow wrist hand orthosis, shoulder cap design, includes
one or more nontorsion joints, elastic bands, turnbuckles, may
include soft interface, straps, custom fabricated, includes fitting and
adjustment A

✽ L3973 Shoulder elbow wrist hand orthosis, abduction positioning (airplane

design), thoracic component and support bar, includes one or more
nontorsion joints, elastic bands, turnbuckles, may include soft
interface, straps, custom fabricated, includes fitting and adjustment
A

Shoulder-Elbow-Wrist-Hand-Finger Orthotics
✽ L3975 Shoulder elbow wrist hand finger orthosis, shoulder cap design,
without joints, may include soft interface, straps, custom fabricated,
includes fitting and adjustment A

✽ L3976 Shoulder elbow wrist hand finger orthosis, abduction positioning

(airplane design), thoracic component and support bar, without
joints, may include soft interface, straps, custom fabricated, includes
fitting and adjustment A

✽ L3977 Shoulder elbow wrist hand finger orthosis, shoulder cap design,
includes one or more nontorsion joints, elastic bands, turnbuckles,
may include soft interface, straps, custom fabricated, includes fitting
and adjustment A

✽ L3978 Shoulder elbow wrist hand finger orthosis, abduction positioning

(airplane design), thoracic component and support bar, includes one
or more nontorsion joints, elastic bands, turnbuckles, may include
 soft interface, straps, custom fabricated, includes fitting and
adjustment A

Fracture Orthorics
✽ L3980 Upper extremity fracture orthosis, humeral, prefabricated, includes
fitting and adjustment A

✽ L3981 Upper extremity fracture orthosis, humeral, prefabricated, includes

shoulder cap design, with or without joints, forearm section, may
include soft interface, straps, includes fitting and adjustments
A

✽ L3982 Upper extremity fracture orthosis, radius/ulnar, prefabricated,

includes fitting and adjustment A

✽ L3984 Upper extremity fracture orthosis, wrist, prefabricated, includes

fitting and adjustment A

✽ L3995 Addition to upper extremity orthosis, sock, fracture or equal, each

A

✽ L3999 Upper limb orthosis, not otherwise specified A

Repairs
✽ L4000 Replace girdle for spinal orthosis (CTLSO or SO) A

✽ L4002 Replacement strap, any orthosis, includes all components, any

length, any type A

✽ L4010 Replace trilateral socket brim A

✽ L4020 Replace quadrilateral socket brim, molded to patient model

A
✽ L4030 Replace quadrilateral socket brim, custom fitted A

✽ L4040 Replace molded thigh lacer, for custom fabricated orthosis only
A

✽ L4045 Replace non-molded thigh lacer, for custom fabricated orthosis only
A

✽ L4050 Replace molded calf lacer, for custom fabricated orthosis only
A

✽ L4055 Replace non-molded calf lacer, for custom fabricated orthosis only
A

✽ L4060 Replace high roll cuff A

✽ L4070 Replace proximal and distal upright for KAFO A

 ✽ L4080 Replace metal bands KAFO, proximal thigh A

✽ L4090 Replace metal bands KAFO-AFO, calf or distal thigh A

✽ L4100 Replace leather cuff KAFO, proximal thigh A

✽ L4110 Replace leather cuff KAFO-AFO, calf or distal thigh A

✽ L4130 Replace pretibial shell A

❂ L4205 Repair of orthotic device, labor component, per 15 minutes A

IOM: 100-02, 15, 110.2

❂ L4210 Repair of orthotic device, repair or replace minor parts A

IOM: 100-02, 15, 110.2; 100-02, 15, 120

Ancillary Orthotic Services

✽ L4350 Ankle control orthosis, stirrup style, rigid, includes any type
interface (e.g., pneumatic, gel), prefabricated, off-the-shelf
A
✽ L4360 Walking boot, pneumatic and/or vacuum, with or without joints,
with or without interface material, prefabricated item that has been
trimmed, bent, molded, assembled, or otherwise customized to fit a
specific patient by an individual with expertise A

Noncovered when walking boots used primarily to relieve pressure,

especially on sole of foot, or are used for patients with foot ulcers
✽ L4361 Walking boot, pneumatic and/or vacuum, with or without joints,
with or without interface material, prefabricated, off-the-shelf
A

✽ L4370 Pneumatic full leg splint, prefabricated, off-the-shelf A

✽ L4386 Walking boot, non-pneumatic, with or without joints, with or

without interface material, prefabricated item that has been trimmed,
bent, molded, assembled, or otherwise customized to fit a specific
patient by an individual with expertise A

✽ L4387 Walking boot, non-pneumatic, with or without joints, with or

without interface material, prefabricated, off-the-shelf
A
✽ L4392 Replacement, soft interface material, static AFO A

✽ L4394 Replace soft interface material, foot drop splint A

✽ L4396 Static or dynamic ankle foot orthosis, including soft interface

material, adjustable for fit, for positioning, may be used for minimal
ambulation, prefabricated item that has been trimmed, bent, molded,
assembled, or otherwise customized to fit a specific patient by an
 individual with expertise A

✽ L4397 Static or dynamic ankle foot orthosis, including soft interface

material, adjustable for fit, for positioning, may be used for minimal
ambulation, prefabricated, off-the-shelf A

✽ L4398 Foot drop splint, recumbent positioning device, prefabricated, off-

the-shelf A

✽ L4631 Ankle foot orthosis, walking boot type, varus/valgus correction,

rocker bottom, anterior tibial shell, soft interface, custom arch
support, plastic or other material, includes straps and closures,
custom fabricated A

Figure 36 Partial foot.

PROSTHETICS (L5000-L9999)
Lower Limb (L5000-L5999)

NOTE: The procedures in this section are considered as base or basic

proceduresand may be modified by listing items/procedures or special materials
from the Additions section and adding them to the base procedure.

Partial Foot
❂ L5000 Partial foot, shoe insert with longitudinal arch, toe filler
A
IOM: 100-02, 15, 290
❂ L5010 Partial foot, molded socket, ankle height, with toe filler
A
IOM: 100-02, 15, 290
❂ L5020 Partial foot, molded socket, tibial tubercle height, with toe filler
 A

IOM: 100-02, 15, 290

Ankle
✽ L5050 Ankle, Symes, molded socket, SACH foot A

✽ L5060 Ankle, Symes, metal frame, molded leather socket, articulated

ankle/foot A

Figure 37 Ankle Symes.

Below Knee
✽ L5100 Below knee, molded socket, shin, SACH foot A

✽ L5105 Below knee, plastic socket, joints and thigh lacer, SACH foot
A

Knee Disarticulation
✽ L5150 Knee disarticulation (or through knee), molded socket, external knee
joints, shin, SACH foot A

✽ L5160 Knee disarticulation (or through knee), molded socket, bent knee
configuration, external knee joints, shin, SACH foot A

Above Knee
✽ L5200 Above knee, molded socket, single axis constant friction knee, shin,
SACH foot A

✽ L5210 Above knee, short prosthesis, no knee joint (‘stubbies’), with foot
blocks, no ankle joints, each A

✽ L5220 Above knee, short prosthesis, no knee joint (‘stubbies’), with

articulated ankle/foot, dynamically aligned, each A

✽ L5230 Above knee, for proximal femoral focal deficiency, constant friction
 knee, shin, SACH foot A

Hip Disarticulation
✽ L5250 Hip disarticulation, Canadian type; molded socket, hip joint, single
axis constant friction knee, shin, SACH foot A

✽ L5270 Hip disarticulation, tilt table type; molded socket, locking hip joint,
single axis constant friction knee, shin, SACH foot A

Figure 38 Above knee.

Hemipelvectomy
✽ L5280 Hemipelvectomy, Canadian type; molded socket, hip joint, single
axis constant friction knee, shin, SACH foot A

Endoskeletal
✽ L5301 Below knee, molded socket, shin, SACH foot, endoskeletal system
A

✽ L5312 Knee disarticulation (or through knee), molded socket, single axis
knee, pylon, sach foot, endoskeletal system A

✽ L5321 Above knee, molded socket, open end, SACH foot, endoskeletal
system, single axis knee A

✽ L5331 Hip disarticulation, Canadian type, molded socket, endoskeletal

system, hip joint, single axis knee, SACH foot A

✽ L5341 Hemipelvectomy, Canadian type, molded socket, endoskeletal

system, hip joint, single axis knee, SACH foot A

Immediate Postsurgical or Early Fitting Procedures

 ✽ L5400 Immediate post surgical or early fitting, application of initial rigid
dressing, including fitting, alignment, suspension, and one cast
change, below knee A

✽ L5410 Immediate post surgical or early fitting, application of initial rigid

dressing, including fitting, alignment and suspension, below knee,
each additional cast change and realignment A

✽ L5420 Immediate post surgical or early fitting, application of initial rigid

dressing, including fitting, alignment and suspension and one cast
change ‘AK’ or knee disarticulation A

✽ L5430 Immediate postsurgical or early fitting, application of initial rigid

dressing, including fitting, alignment, and suspension, ‘AK’ or knee
disarticulation, each additional cast change and realignment
A

✽ L5450 Immediate post surgical or early fitting, application of non-weight

bearing rigid dressing, below knee A

✽ L5460 Immediate post surgical or early fitting, application of non-weight

bearing rigid dressing, above knee A

Initial Prosthesis
✽ L5500 Initial, below knee ‘PTB’ type socket, non-alignable system, pylon,
no cover, SACH foot, plaster socket, direct formed A

✽ L5505 Initial, above knee-knee disarticulation, ischial level socket, non-

alignable system, pylon, no cover, SACH foot, plaster socket, direct
formed A

Preparatory Prosthesis
✽ L5510 Preparatory, below knee ‘PTB’ type socket, non-alignable system,
pylon, no cover, SACH foot, plaster socket, molded to model
A

✽ L5520 Preparatory, below knee ‘PTB’ type socket, non-alignable system,

pylon, no cover, SACH foot, thermoplastic or equal, direct formed
A

✽ L5530 Preparatory, below knee ‘PTB’ type socket, non-alignable system,

pylon, no cover, SACH foot, thermoplastic or equal, molded to
model A

✽ L5535 Preparatory, below knee ‘PTB’ type socket, non-alignable system,

no cover, SACH foot, prefabricated, adjustable open end socket
A
 ✽ L5540 Preparatory, below knee ‘PTB’ type socket, non-alignable system,
pylon, no cover, SACH foot, laminated socket, molded to model
A

✽ L5560 Preparatory, above knee - knee disarticulation, ischial level socket,

non-alignable system, pylon, no cover, SACH foot, plaster socket,
molded to model A

✽ L5570 Preparatory, above knee - knee disarticulation, ischial level socket,

non-alignable system, pylon, no cover, SACH foot, thermoplastic or
equal, direct formed A

✽ L5580 Preparatory, above knee - knee disarticulation, ischial level socket,

non-alignable system, pylon, no cover, SACH foot, thermoplastic or
equal, molded to model A

✽ L5585 Preparatory, above knee - knee disarticulation, ischial level socket,

non-alignable system, pylon, no cover, SACH foot, prefabricated
adjustable open end socket A

✽ L5590 Preparatory, above knee - knee disarticulation, ischial level socket,

non-alignable system, pylon, no cover, SACH foot, laminated
socket, molded to model A

✽ L5595 Preparatory, hip disarticulation-hemipelvectomy, pylon, no cover,

SACH foot, thermoplastic or equal, molded to patient model
A

✽ L5600 Preparatory, hip disarticulation-hemipelvectomy, pylon, no cover,

SACH foot, laminated socket, molded to patient model
A

Additions to Lower Extremity

✽ L5610 Addition to lower extremity, endoskeletal system, above knee,
hydracadence system A

✽ L5611 Addition to lower extremity, endoskeletal system, above knee-knee

disarticulation, 4 bar linkage, with friction swing phase control
A

✽ L5613 Addition to lower extremity, endoskeletal system, above knee-knee

disarticulation, 4 bar linkage, with hydraulic swing phase control
A

✽ L5614 Addition to lower extremity, exoskeletal system, above knee-knee

disarticulation, 4 bar linkage, with pneumatic swing phase control
A

✽ L5616 Addition to lower extremity, endoskeletal system, above knee,

universal multiplex system, friction swing phase control
 A
✽ L5617 Addition to lower extremity, quick change self-aligning unit, above
knee or below knee, each A

Additions to Test Sockets

✽ L5618 Addition to lower extremity, test socket, Symes A

✽ L5620 Addition to lower extremity, test socket, below knee A

✽ L5622 Addition to lower extremity, test socket, knee disarticulation

A
✽ L5624 Addition to lower extremity, test socket, above knee A

✽ L5626 Addition to lower extremity, test socket, hip disarticulation

A
✽ L5628 Addition to lower extremity, test socket, hemipelvectomy
A

Additions to Socket Variations

✽ L5629 Addition to lower extremity, below knee, acrylic socket
A
✽ L5630 Addition to lower extremity, Symes type, expandable wall socket
A

✽ L5631 Addition to lower extremity, above knee or knee disarticulation,

acrylic socket A

✽ L5632 Addition to lower extremity, Symes type, ‘PTB’ brim design socket
A

✽ L5634 Addition to lower extremity, Symes type, posterior opening

(Canadian) socket A

✽ L5636 Addition to lower extremity, Symes type, medial opening socket

A

✽ L5637 Addition to lower extremity, below knee, total contact

A
✽ L5638 Addition to lower extremity, below knee, leather socket
A
✽ L5639 Addition to lower extremity, below knee, wood socket
A
✽ L5640 Addition to lower extremity, knee disarticulation, leather socket
A

✽ L5642 Addition to lower extremity, above knee, leather socket

A
✽ L5643 Addition to lower extremity, hip disarticulation, flexible inner
socket, external frame A

✽ L5644 Addition to lower extremity, above knee, wood socket

 A
✽ L5645 Addition to lower extremity, below knee, flexible inner socket,
external frame A

✽ L5646 Addition to lower extremity, below knee, air, fluid, gel or equal,
cushion socket A

✽ L5647 Addition to lower extremity, below knee, suction socket

A
✽ L5648 Addition to lower extremity, above knee, air, fluid, gel or equal,
cushion socket A

✽ L5649 Addition to lower extremity, ischial containment/narrow M-L socket

A

✽ L5650 Additions to lower extremity, total contact, above knee or knee

disarticulation socket A

✽ L5651 Addition to lower extremity, above knee, flexible inner socket,

external frame A

✽ L5652 Addition to lower extremity, suction suspension, above knee or knee

disarticulation socket A

✽ L5653 Addition to lower extremity, knee disarticulation, expandable wall

socket A

Additions to Socket Insert and Suspension

✽ L5654 Addition to lower extremity, socket insert, Symes, (Kemblo, Pelite,
Aliplast, Plastazote or equal) A

✽ L5655 Addition to lower extremity, socket insert, below knee (Kemblo,

Pelite, Aliplast, Plastazote or equal) A

✽ L5656 Addition to lower extremity, socket insert, knee disarticulation

(Kemblo, Pelite, Aliplast, Plastazote or equal) A

✽ L5658 Addition to lower extremity, socket insert, above knee (Kemblo,

Pelite, Aliplast, Plastazote or equal) A

✽ L5661 Addition to lower extremity, socket insert, multi-durometer Symes

A

✽ L5665 Addition to lower extremity, socket insert, multi-durometer, below

knee A

✽ L5666 Addition to lower extremity, below knee, cuff suspension

A
✽ L5668 Addition to lower extremity, below knee, molded distal cushion
A

✽ L5670 Addition to lower extremity, below knee, molded supracondylar

 suspension (‘PTS’ or similar) A

✽ L5671 Addition to lower extremity, below knee/above knee suspension

locking mechanism (shuttle, lanyard or equal), excludes socket
insert A

✽ L5672 Addition to lower extremity, below knee, removable medial brim

suspension A

✽ L5673 Addition to lower extremity, below knee/above knee, custom

fabricated from existing mold or prefabricated, socket insert,
silicone gel, elastomeric or equal, for use with locking mechanism
A

✽ L5676 Additions to lower extremity, below knee, knee joints, single axis,
pair A

✽ L5677 Additions to lower extremity, below knee, knee joints, polycentric,

pair A

✽ L5678 Additions to lower extremity, below knee, joint covers, pair

A

✽ L5679 Addition to lower extremity, below knee/above knee, custom

fabricated from existing mold or prefabricated, socket insert,
silicone gel, elastomeric or equal, not for use with locking
mechanism A

✽ L5680 Addition to lower extremity, below knee, thigh lacer, nonmolded

A

✽ L5681 Addition to lower extremity, below knee/above knee, custom

fabricated socket insert for congenital or atypical traumatic
amputee, silicone gel, elastomeric or equal, for use with or without
locking mechanism, initial only (for other than initial, use code
L5673 or L5679) A

✽ L5682 Addition to lower extremity, below knee, thigh lacer, gluteal/ischial,

molded A

✽ L5683 Addition to lower extremity, below knee/above knee, custom

fabricated socket insert for other than congenital or atypical
traumatic amputee, silicone gel, elastomeric, or equal, for use with
or without locking mechanism, initial only (for other than initial, use
code L5673 or L5679) A

✽ L5684 Addition to lower extremity, below knee, fork strap A

✽ L5685 Addition to lower extremity prosthesis, below knee,

suspension/sealing sleeve, with or without valve, any material, each
A
 ✽ L5686 Addition to lower extremity, below knee, back check (extension
control) A

✽ L5688 Addition to lower extremity, below knee, waist belt, webbing

A

✽ L5690 Addition to lower extremity, below knee, waist belt, padded and
lined A

✽ L5692 Addition to lower extremity, above knee, pelvic control belt, light
A

✽ L5694 Addition to lower extremity, above knee, pelvic control belt, padded
and lined A

✽ L5695 Addition to lower extremity, above knee, pelvic control, sleeve

suspension, neoprene or equal, each A

✽ L5696 Addition to lower extremity, above knee or knee disarticulation,

pelvic joint A

✽ L5697 Addition to lower extremity, above knee or knee disarticulation,

pelvic band A

✽ L5698 Addition to lower extremity, above knee or knee disarticulation,

Silesian bandage A

✽ L5699 All lower extremity prostheses, shoulder harness A

Replacement Sockets
✽ L5700 Replacement, socket, below knee, molded to patient model
A
✽ L5701 Replacement, socket, above knee/knee disarticulation, including
attachment plate, molded to patient model A

✽ L5702 Replacement, socket, hip disarticulation, including hip joint, molded

to patient model A

✽ L5703 Ankle, Symes, molded to patient model, socket without solid ankle
cushion heel (SACH) foot, replacement only A

Protective Covers
✽ L5704 Custom shaped protective cover, below knee A

✽ L5705 Custom shaped protective cover, above knee A

✽ L5706 Custom shaped protective cover, knee disarticulation A

✽ L5707 Custom shaped protective cover, hip disarticulation A

Additions to Exoskeletal–Knee-Shin System
✽ L5710 Addition, exoskeletal knee-shin system, single axis, manual lock
A

✽ L5711 Additions exoskeletal knee-shin system, single axis, manual lock,

ultra-light material A

✽ L5712 Addition, exoskeletal knee-shin system, single axis, friction swing

and stance phase control (safety knee) A

✽ L5714 Addition, exoskeletal knee-shin system, single axis, variable friction

swing phase control A

✽ L5716 Addition, exoskeletal knee-shin system, polycentric, mechanical

stance phase lock A

✽ L5718 Addition, exoskeletal knee-shin system, polycentric, friction swing

and stance phase control A

✽ L5722 Addition, exoskeletal knee-shin system, single axis, pneumatic

swing, friction stance phase control A

✽ L5724 Addition, exoskeletal knee-shin system, single axis, fluid swing

phase control A

✽ L5726 Addition, exoskeletal knee-shin system, single axis, external joints,

fluid swing phase control A

✽ L5728 Addition, exoskeletal knee-shin system, single axis, fluid swing and
stance phase control A

✽ L5780 Addition, exoskeletal knee-shin system, single axis,

pneumatic/hydra pneumatic swing phase control A

Vacuum Pumps
✽ L5781 Addition to lower limb prosthesis, vacuum pump, residual limb
volume management and moisture evacuation system A

✽ L5782 Addition to lower limb prosthesis, vacuum pump, residual limb

volume management and moisture evacuation system, heavy duty
A

Component Modification
✽ L5785 Addition, exoskeletal system, below knee, ultra-light material
(titanium, carbon fiber, or equal) A

✽ L5790 Addition, exoskeletal system, above knee, ultra-light material

(titanium, carbon fiber, or equal) A

✽ L5795 Addition, exoskeletal system, hip disarticulation, ultra-light material

 (titanium, carbon fiber, or equal) A

Endoskeletal
✽ L5810 Addition, endoskeletal knee-shin system, single axis, manual lock
A

✽ L5811 Addition, endoskeletal knee-shin system, single axis, manual lock,

ultralight material A

✽ L5812 Addition, endoskeletal knee-shin system, single axis, friction swing

and stance phase control (safety knee) A

✽ L5814 Addition, endoskeletal knee-shin system, polycentric, hydraulic

swing phase control, mechanical stance phase lock A

✽ L5816 Addition, endoskeletal knee-shin system, polycentric, mechanical

stance phase lock A

✽ L5818 Addition, endoskeletal knee-shin system, polycentric, friction

swing, and stance phase control A

✽ L5822 Addition, endoskeletal knee-shin system, single axis, pneumatic

swing, friction stance phase control A

✽ L5824 Addition, endoskeletal knee-shin system, single axis, fluid swing

phase control A

✽ L5826 Addition, endoskeletal knee-shin system, single axis, hydraulic

swing phase control, with miniature high activity frame
A
✽ L5828 Addition, endoskeletal knee-shin system, single axis, fluid swing
and stance phase control A

✽ L5830 Addition, endoskeletal knee-shin system, single axis,

pneumatic/swing phase control A

✽ L5840 Addition, endoskeletal knee/shin system, 4-bar linkage or

multiaxial, pneumatic swing phase control A

✽ L5845 Addition, endoskeletal, knee-shin system, stance flexion feature,

adjustable A

✽ L5848 Addition to endoskeletal, knee-shin system, fluid stance extension,

dampening feature, with or without adjustability A

✽ L5850 Addition, endoskeletal system, above knee or hip disarticulation,

knee extension assist A

✽ L5855 Addition, endoskeletal system, hip disarticulation, mechanical hip

extension assist A

✽ L5856 Addition to lower extremity prosthesis, endoskeletal knee-shin

system, microprocessor control feature, swing and stance phase;
 includes electronic sensor(s), any type A

✽ L5857 Addition to lower extremity prosthesis, endoskeletal knee-shin

system, microprocessor control feature, swing phase only; includes
electronic sensor(s), any type A

✽ L5858 Addition to lower extremity prosthesis, endoskeletal knee shin

system, microprocessor control feature, stance phase only, includes
electronic sensor(s), any type A

✽ L5859 Addition to lower extremity prosthesis, endoskeletal knee-shin

system, powered and programmable flexion/extension assist control,
includes any type motor(s) A

✽ L5910 Addition, endoskeletal system, below knee, alignable system

A

✽ L5920 Addition, endoskeletal system, above knee or hip disarticulation,

alignable system A

✽ L5925 Addition, endoskeletal system, above knee, knee disarticulation or

hip disarticulation, manual lock A

✽ L5930 Addition, endoskeletal system, high activity knee control frame

A

✽ L5940 Addition, endoskeletal system, below knee, ultra-light material

(titanium, carbon fiber or equal) A

✽ L5950 Addition, endoskeletal system, above knee, ultra-light material

(titanium, carbon fiber or equal) A

✽ L5960 Addition, endoskeletal system, hip disarticulation, ultra-light

material (titanium, carbon fiber, or equal) A

✽ L5961 Addition, endoskeletal system, polycentric hip joint, pneumatic or

hydraulic control, rotation control, with or without flexion, and/or
extension control A

✽ L5962 Addition, endoskeletal system, below knee, flexible protective outer

surface covering system A

✽ L5964 Addition, endoskeletal system, above knee, flexible protective outer

surface covering system A

✽ L5966 Addition, endoskeletal system, hip disarticulation, flexible

protective outer surface covering system A

Additions to Ankle and/or Foot

✽ L5968 Addition to lower limb prosthesis, multiaxial ankle with swing
phase active dorsiflexion feature A
✽ L5969 Addition, endoskeletal ankle-foot or ankle system, power assist,
includes any type motor(s) A

✽ L5970 All lower extremity prostheses, foot, external keel, SACH foot
A

✽ L5971 All lower extremity prosthesis, solid ankle cushion keel (SACH)
foot, replacement only A

✽ L5972 All lower extremity prostheses (foot, flexible keel) A

✽ L5973 Endoskeletal ankle foot system, microprocessor controlled feature,

dorsiflexion and/or plantar flexion control, includes power source
A

✽ L5974 All lower extremity prostheses, foot, single axis ankle/foot

A
✽ L5975 All lower extremity prostheses, combination single axis ankle and
flexible keel foot A

✽ L5976 All lower extremity prostheses, energy storing foot (Seattle Carbon
Copy II or equal) A

✽ L5978 All lower extremity prostheses, foot, multiaxial ankle/foot

A
✽ L5979 All lower extremity prostheses, multiaxial ankle, dynamic response
foot, one piece system A

✽ L5980 All lower extremity prostheses, flex foot system A

✽ L5981 All lower extremity prostheses, flexwalk system or equal

A
✽ L5982 All exoskeletal lower extremity prostheses, axial rotation unit
A

✽ L5984 All endoskeletal lower extremity prostheses, axial rotation unit, with
or without adjustability A

✽ L5985 All endoskeletal lower extremity prostheses, dynamic prosthetic

pylon A

✽ L5986 All lower extremity prostheses, multiaxial rotation unit (‘MCP’ or

equal) A

✽ L5987 All lower extremity prostheses, shank foot system with vertical
loading pylon A

✽ L5988 Addition to lower limb prosthesis, vertical shock reducing pylon

feature A

✽ L5990 Addition to lower extremity prosthesis, user adjustable heel height

A

✽ L5999 Lower extremity prosthesis, not otherwise specified A

Upper Limb (L6000-L7600)

NOTE: The procedures in L6000-L6599 are considered as base or basic

procedures and may be modified by listing procedures from the additions
sections. The base procedures include only standard friction wrist and control
cable system unless otherwise specified.

Partial Hand
✽ L6000 Partial hand, thumb remaining A

✽ L6010 Partial hand, little and/or ring finger remaining A

✽ L6020 Partial hand, no finger remaining A

✽ L6026 Transcarpal/metacarpal or partial hand disarticulation prosthesis,

external power, self-suspended, inner socket with removable
forearm section, electrodes and cables, two batteries, charger,
myoelectric control of terminal device, excludes terminal device(s)
A

Figure 39 Partial hand.

Wrist Disarticulation
✽ L6050 Wrist disarticulation, molded socket, flexible elbow hinges, triceps
pad A

✽ L6055 Wrist disarticulation, molded socket with expandable interface,

flexible elbow hinges, triceps pad A

Below Elbow
 ✽ L6100 Below elbow, molded socket, flexible elbow hinge, triceps pad
A

✽ L6110 Below elbow, molded socket, (Muenster or Northwestern

suspension types) A

✽ L6120 Below elbow, molded double wall split socket, step-up hinges, half
cuff A

✽ L6130 Below elbow, molded double wall split socket, stump activated
locking hinge, half cuff A

Elbow Disarticulation
✽ L6200 Elbow disarticulation, molded socket, outside locking hinge,
forearm A

✽ L6205 Elbow disarticulation, molded socket with expandable interface,

outside locking hinges, forearm A

Above Elbow
✽ L6250 Above elbow, molded double wall socket, internal locking elbow,
forearm A

Shoulder Disarticulation
✽ L6300 Shoulder disarticulation, molded socket, shoulder bulkhead,
humeral section, internal locking elbow, forearm A

✽ L6310 Shoulder disarticulation, passive restoration (complete prosthesis)

A

✽ L6320 Shoulder disarticulation, passive restoration (shoulder cap only)

A

Interscapular Thoracic
✽ L6350 Interscapular thoracic, molded socket, shoulder bulkhead, humeral
section, internal locking elbow, forearm A

✽ L6360 Interscapular thoracic, passive restoration (complete prosthesis)

A

✽ L6370 Interscapular thoracic, passive restoration (shoulder cap only)

A

Immediate and Early Postsurgical Procedures

Immediate post surgical or early fitting, application of initial rigid
 ✽ L6380 dressing, including fitting alignment and suspension of components,
and one cast change, wrist disarticulation or below elbow
A
✽ L6382 Immediate post surgical or early fitting, application of initial rigid
dressing including fitting alignment and suspension of components,
and one cast change, elbow disarticulation or above elbow
A
✽ L6384 Immediate post surgical or early fitting, application of initial rigid
dressing including fitting alignment and suspension of components,
and one cast change, shoulder disarticulation or interscapular
thoracic A

✽ L6386 Immediate post surgical or early fitting, each additional cast change
and realignment A

✽ L6388 Immediate post surgical or early fitting, application of rigid dressing

only A

Molded Socket
✽ L6400 Below elbow, molded socket, endoskeletal system, including soft
prosthetic tissue shaping A

✽ L6450 Elbow disarticulation, molded socket, endoskeletal system,

including soft prosthetic tissue shaping A

✽ L6500 Above elbow, molded socket, endoskeletal system, including soft

prosthetic tissue shaping A

✽ L6550 Shoulder disarticulation, molded socket, endoskeletal system,

including soft prosthetic tissue shaping A

✽ L6570 Interscapular thoracic, molded socket, endoskeletal system,

including soft prosthetic tissue shaping A

Preparatory Prosthetic
✽ L6580 Preparatory, wrist disarticulation or below elbow, single wall plastic
socket, friction wrist, flexible elbow hinges, figure of eight harness,
humeral cuff, Bowden cable control, USMC or equal pylon, no
cover, molded to patient model A

✽ L6582 Preparatory, wrist disarticulation or below elbow, single wall socket,

friction wrist, flexible elbow hinges, figure of eight harness,
humeral cuff, Bowden cable control, USMC or equal pylon, no
cover, direct formed A

✽ L6584 Preparatory, elbow disarticulation or above elbow, single wall

plastic socket, friction wrist, locking elbow, figure of eight harness,
 fair lead cable control, USMC or equal pylon, no cover, molded to
patient model A

✽ L6586 Preparatory, elbow disarticulation or above elbow, single wall

socket, friction wrist, locking elbow, figure of eight harness, fair
lead cable control, USMC or equal pylon, no cover, direct formed
A

✽ L6588 Preparatory, shoulder disarticulation or interscapular thoracic, single

wall plastic socket, shoulder joint, locking elbow, friction wrist,
chest strap, fair lead cable control, USMC or equal pylon, no cover,
molded to patient model A

✽ L6590 Preparatory, shoulder disarticulation or interscapular thoracic, single

wall socket, shoulder joint, locking elbow, friction wrist, chest strap,
fair lead cable control, USMC or equal pylon, no cover, direct
formed A

Additions to Upper Limb

NOTE: The following procedures/modifications/components may be added to

other base procedures. The items in this section should reflect the additional
complexity of each modification procedure, in addition to base procedure, at the
time of the original order.
✽ L6600 Upper extremity additions, polycentric hinge, pair A

✽ L6605 Upper extremity additions, single pivot hinge, pair A

✽ L6610 Upper extremity additions, flexible metal hinge, pair A

✽ L6611 Addition to upper extremity prosthesis, external powered, additional

switch, any type A

✽ L6615 Upper extremity addition, disconnect locking wrist unit

A
✽ L6616 Upper extremity addition, additional disconnect insert for locking
wrist unit, each A

✽ L6620 Upper extremity addition, flexion/extension wrist unit, with or

without friction A

✽ L6621 Upper extremity prosthesis addition, flexion/extension wrist with or

without friction, for use with external powered terminal device
A

✽ L6623 Upper extremity addition, spring assisted rotational wrist unit with
latch release A

✽ L6624 Upper extremity addition, flexion/extension and rotation wrist unit

 A

✽ L6625 Upper extremity addition, rotation wrist unit with cable lock
A

✽ L6628 Upper extremity addition, quick disconnect hook adapter, Otto Bock
or equal A

✽ L6629 Upper extremity addition, quick disconnect lamination collar with

coupling piece, Otto Bock or equal A

✽ L6630 Upper extremity addition, stainless steel, any wrist A

✽ L6632 Upper extremity addition, latex suspension sleeve, each A

✽ L6635 Upper extremity addition, lift assist for elbow A

✽ L6637 Upper extremity addition, nudge control elbow lock A

✽ L6638 Upper extremity addition to prosthesis, electric locking feature, only

for use with manually powered elbow A

✽ L6640 Upper extremity additions, shoulder abduction joint, pair

A

Figure 40 Upper extremity addition.

✽ L6641 Upper extremity addition, excursion amplifier, pulley type

A
✽ L6642 Upper extremity addition, excursion amplifier, lever type
A
✽ L6645 Upper extremity addition, shoulder flexion-abduction joint, each
A

✽ L6646 Upper extremity addition, shoulder joint, multipositional locking,

flexion, adjustable abduction friction control, for use with body
powered or external powered system A

✽ L6647 Upper extremity addition, shoulder lock mechanism, body powered

actuator A

✽ L6648 Upper extremity addition, shoulder lock mechanism, external

 powered actuator A

✽ L6650 Upper extremity addition, shoulder universal joint, each

A
✽ L6655 Upper extremity addition, standard control cable, extra A

✽ L6660 Upper extremity addition, heavy duty control cable A

✽ L6665 Upper extremity addition, Teflon, or equal, cable lining A

✽ L6670 Upper extremity addition, hook to hand, cable adapter

A
✽ L6672 Upper extremity addition, harness, chest or shoulder, saddle type
A

✽ L6675 Upper extremity addition, harness, (e.g., figure of eight type), single
cable design A

✽ L6676 Upper extremity addition, harness, (e.g., figure of eight type), dual
cable design A

✽ L6677 Upper extremity addition, harness, triple control, simultaneous

operation of terminal device and elbow A

✽ L6680 Upper extremity addition, test socket, wrist disarticulation or below

elbow A

✽ L6682 Upper extremity addition, test socket, elbow disarticulation or above

elbow A

✽ L6684 Upper extremity addition, test socket, shoulder disarticulation or

interscapular thoracic A

✽ L6686 Upper extremity addition, suction socket A

✽ L6687 Upper extremity addition, frame type socket, below elbow or wrist
disarticulation A

✽ L6688 Upper extremity addition, frame type socket, above elbow or elbow
disarticulation A

✽ L6689 Upper extremity addition, frame type socket, shoulder

disarticulation A

✽ L6690 Upper extremity addition, frame type socket, interscapular-thoracic

A

✽ L6691 Upper extremity addition, removable insert, each A

✽ L6692 Upper extremity addition, silicone gel insert or equal, each

A
✽ L6693 Upper extremity addition, locking elbow, forearm counterbalance
A

✽ L6694 Addition to upper extremity prosthesis, below elbow/above elbow,

custom fabricated from existing mold or prefabricated, socket insert,
 silicone gel, elastomeric or equal, for use with locking mechanism
A

✽ L6695 Addition to upper extremity prosthesis, below elbow/above elbow,

custom fabricated from existing mold or prefabricated, socket insert,
silicone gel, elastomeric or equal, not for use with locking
mechanism A

✽ L6696 Addition to upper extremity prosthesis, below elbow/above elbow,

custom fabricated socket insert for congenital or atypical traumatic
amputee, silicone gel, elastomeric or equal, for use with or without
locking mechanism, initial only (for other than initial, use code
L6694 or L6695) A

✽ L6697 Addition to upper extremity prosthesis, below elbow/above elbow,

custom fabricated socket insert for other than congenital or atypical
traumatic amputee, silicone gel, elastomeric or equal, for use with or
without locking mechanism, initial only (for other than initial, use
code L6694 or L6695) A

✽ L6698 Addition to upper extremity prosthesis, below elbow/above elbow,

lock mechanism, excludes socket insert A

Terminal Devices (L6703-L6882)

✽ L6703 Terminal device, passive hand/mitt, any material, any size
A
✽ L6704 Terminal device, sport/recreational/work attachment, any material,
any size A

✽ L6706 Terminal device, hook, mechanical, voluntary opening, any

material, any size, lined or unlined A

✽ L6707 Terminal device, hook, mechanical, voluntary closing, any material,

any size, lined or unlined A

✽ L6708 Terminal device, hand, mechanical, voluntary opening, any material,

any size A

✽ L6709 Terminal device, hand, mechanical, voluntary closing, any material,

any size A

✽ L6711 Terminal device, hook, mechanical, voluntary opening, any

material, any size, lined or unlined, pediatric A

✽ L6712 Terminal device, hook, mechanical, voluntary closing, any material,

any size, lined or unlined, pediatric A

✽ L6713 Terminal device, hand, mechanical, voluntary opening, any material,

any size, pediatric A
 ✽ L6714 Terminal device, hand, mechanical, voluntary closing, any material,
any size, pediatric A

✽ L6715 Terminal device, multiple articulating digit, includes motor(s),

initial issue or replacement A

✽ L6721 Terminal device, hook or hand, heavy duty, mechanical, voluntary

opening, any material, any size, lined or unlined A

✽ L6722 Terminal device, hook or hand, heavy duty, mechanical, voluntary

closing, any material, any size, lined or unlined A

❂ L6805 Addition to terminal device, modifier wrist unit A

IOM: 100-02, 15, 120; 100-04, 3, 10.4

❂ L6810 Addition to terminal device, precision pinch device A

IOM: 100-02, 15, 120; 100-04, 3, 10.4

Figure 41 Terminal devices, hand and hook.

✽ L6880 Electric hand, switch or myoelectric controlled, independently

articulating digits, any grasp pattern or combination of grasp
patterns, includes motor(s) A

✽ L6881 Automatic grasp feature, addition to upper limb electric prosthetic

terminal device A

❂ L6882 Microprocessor control feature, addition to upper limb prosthetic

terminal device A

IOM: 100-02, 15, 120; 100-04, 3, 10.4

Replacement Sockets
✽ L6883 Replacement socket, below elbow/wrist disarticulation, molded to
patient model, for use with or without external power A
 ✽ L6884 Replacement socket, above elbow/elbow disarticulation, molded to
patient model, for use with or without external power A

✽ L6885 Replacement socket, shoulder disarticulation/interscapular thoracic,

molded to patient model, for use with or without external power
A

Hand Restoration
✽ L6890 Addition to upper extremity prosthesis, glove for terminal device,
any material, prefabricated, includes fitting and adjustment
A
✽ L6895 Addition to upper extremity prosthesis, glove for terminal device,
any material, custom fabricated A

✽ L6900 Hand restoration (casts, shading and measurements included),

partial hand, with glove, thumb or one finger remaining
A
✽ L6905 Hand restoration (casts, shading and measurements included),
partial hand, with glove, multiple fingers remaining A

✽ L6910 Hand restoration (casts, shading and measurements included),

partial hand, with glove, no fingers remaining A

✽ L6915 Hand restoration (shading, and measurements included),

replacement glove for above A

External Power
✽ L6920 Wrist disarticulation, external power, self-suspended inner socket,
removable forearm shell, Otto Bock or equal switch, cables, two
batteries and one charger, switch control of terminal device
A
✽ L6925 Wrist disarticulation, external power, self-suspended inner socket,
removable forearm shell, Otto Bock or equal electrodes, cables, two
batteries and one charger, myoelectronic control of terminal device
A

✽ L6930 Below elbow, external power, self-suspended inner socket,

removable forearm shell, Otto Bock or equal switch, cables, two
batteries and one charger, switch control of terminal device
A
✽ L6935 Below elbow, external power, self-suspended inner socket,
removable forearm shell, Otto Bock or equal electrodes, cables, two
batteries and one charger, myoelectronic control of terminal device
A
 ✽ L6940 Elbow disarticulation, external power, molded inner socket,
removable humeral shell, outside locking hinges, forearm, Otto
Bock or equal switch, cables, two batteries and one charger, switch
control of terminal device A

✽ L6945 Elbow disarticulation, external power, molded inner socket,

removable humeral shell, outside locking hinges, forearm, Otto
Bock or equal electrodes, cables, two batteries and one charger,
myoelectronic control of terminal device A

✽ L6950 Above elbow, external power, molded inner socket, removable

humeral shell, internal locking elbow, forearm, Otto Bock or equal
switch, cables, two batteries and one charger, switch control of
terminal device A

✽ L6955 Above elbow, external power, molded inner socket, removable

humeral shell, internal locking elbow, forearm, Otto Bock or equal
electrodes, cables, two batteries and one charger, myoelectronic
control of terminal device A

✽ L6960 Shoulder disarticulation, external power, molded inner socket,

removable shoulder shell, shoulder bulkhead, humeral section,
mechanical elbow, forearm, Otto Bock or equal switch, cables, two
batteries and one charger, switch control of terminal device
A
✽ L6965 Shoulder disarticulation, external power, molded inner socket,
removable shoulder shell, shoulder bulkhead, humeral section,
mechanical elbow, forearm, Otto Bock or equal electrodes, cables,
two batteries and one charger, myoelectronic control of terminal
device A

✽ L6970 Interscapular-thoracic, external power, molded inner socket,

removable shoulder shell, shoulder bulkhead, humeral section,
mechanical elbow, forearm, Otto Bock or equal switch, cables, two
batteries and one charger, switch control of terminal device
A
✽ L6975 Interscapular-thoracic, external power, molded inner socket,
removable shoulder shell, shoulder bulkhead, humeral section,
mechanical elbow, forearm, Otto Bock or equal electrodes, cables,
two batteries and one charger, myoelectronic control of terminal
device A

Additions to Electronic Hand or Hook

✽ L7007 Electric hand, switch or myoelectric controlled, adult
A
 ✽ L7008 Electric hand, switch or myoelectric controlled, pediatric
A

✽ L7009 Electric hook, switch or myoelectric controlled, adult

A
✽ L7040 Prehensile actuator, switch controlled A

✽ L7045 Electric hook, switch or myoelectric controlled, pediatric

A

Additions to Electronic Elbow

✽ L7170 Electronic elbow, Hosmer or equal, switch controlled A

✽ L7180 Electronic elbow, microprocessor sequential control of elbow and

terminal device A

✽ L7181 Electronic elbow, microprocessor simultaneous control of elbow and

terminal device A

✽ L7185 Electronic elbow, adolescent, Variety Village or equal, switch

controlled A

✽ L7186 Electronic elbow, child, Variety Village or equal, switch controlled

A

✽ L7190 Electronic elbow, adolescent, Variety Village or equal,

myoelectronically controlled A

✽ L7191 Electronic elbow, child, Variety Village or equal, myoelectronically

controlled A

Wrist
✽ L7259 Electronic wrist rotator, any type A

Figure 42 Electronic elbow.

Battery Components
✽ L7360 Six volt battery, each A
 ✽ L7362 Battery charger, six volt, each A

✽ L7364 Twelve volt battery, each A

✽ L7366 Battery charger, twelve volt, each A

✽ L7367 Lithium ion battery, rechargeable, replacement A

✽ L7368 Lithium ion battery charger, replacement only A

Additions
✽ L7400 Addition to upper extremity prosthesis, below elbow/wrist
disarticulation, ultralight material (titanium, carbon fiber or equal)
A

✽ L7401 Addition to upper extremity prosthesis, above elbow disarticulation,

ultralight material (titanium, carbon fiber or equal) A

✽ L7402 Addition to upper extremity prosthesis, shoulder

disarticulation/interscapular thoracic, ultralight material (titanium,
carbon fiber or equal) A

✽ L7403 Addition to upper extremity prosthesis, below elbow/wrist

disarticulation, acrylic material A

✽ L7404 Addition to upper extremity prosthesis, above elbow disarticulation,

acrylic material A

✽ L7405 Addition to upper extremity prosthesis, shoulder

disarticulation/interscapular thoracic, acrylic material A

Other/Repair
✽ L7499 Upper extremity prosthesis, not otherwise specified A

❂ L7510 Repair of prosthetic device, repair or replace minor parts

A
IOM: 100-02, 15, 110.2; 100-02, 15, 120; 100-04, 32, 100
✽ L7520 Repair prosthetic device, labor component, per 15 minutes A

L7600 Prosthetic donning sleeve, any material, each E1

Medicare Statute 1862(1)(a)

General

Prosthetic Socket Insert

✽ L7700 Gasket or seal, for use with prosthetic socket insert, any type, each
A
Penile Prosthetics
L7900 Male vacuum erection system ♂ E1

Medicare Statute 1834a

L7902 Tension ring, for vacuum erection device, any type, replacement
only, each E1

Medicare Statute 1834a

Breast Prosthetics
❂ L8000 Breast prosthesis, mastectomy bra, without integrated breast
prosthesis form, any size, any type ♀ A

IOM: 100-02, 15, 120

❂ L8001 Breast prosthesis, mastectomy bra, with integrated breast prosthesis
form, unilateral, any size, any type ♀ A

IOM: 100-02, 15, 120

❂ L8002 Breast prosthesis, mastectomy bra, with integrated breast prosthesis
form, bilateral, any size, any type ♀ A

IOM: 100-02, 15, 120

❂ L8010 Breast prosthesis, mastectomy sleeve ♀ A

IOM: 100-02, 15, 120

❂ L8015 External breast prosthesis garment, with mastectomy form, post
mastectomy ♀ A

IOM: 100-02, 15, 120

❂ L8020 Breast prosthesis, mastectomy form ♀ A

IOM: 100-02, 15, 120

❂ L8030 Breast prosthesis, silicone or equal, without integral adhesive
♀ A

IOM: 100-02, 15, 120

❂ L8031 Breast prosthesis, silicone or equal, with integral adhesive
A
IOM: 100-02, 15, 120
✽ L8032 Nipple prosthesis, prefabricated, reusable, any type, each
A
✽ L8033 Nipple prosthesis, custom fabricated, reusable, any material, any
type, each A

❂ L8035 Custom breast prosthesis, post mastectomy, molded to patient model

 ♀ A

IOM: 100-02, 15, 120

✽ L8039 Breast prosthesis, not otherwise specified ♀ A

Nasal, Orbital, Auricular Prostherics

✽ L8040 Nasal prosthesis, provided by a nonphysician A

✽ L8041 Midfacial prosthesis, provided by a non-physician A

✽ L8042 Orbital prosthesis, provided by a nonphysician A

✽ L8043 Upper facial prosthesis, provided by a non-physician A

✽ L8044 Hemi-facial prosthesis, provided by a non-physician A

✽ L8045 Auricular prosthesis, provided by a non-physician A

✽ L8046 Partial facial prosthesis, provided by a non-physician A

✽ L8047 Nasal septal prosthesis, provided by a non-physician A

✽ L8048 Unspecified maxillofacial prosthesis, by report, provided by a

nonphysician A

✽ L8049 Repair or modification of maxillofacial prosthesis, labor component,

15 minute increments, provided by a nonphysician A

Trusses
❂ L8300 Truss, single with standard pad A

IOM: 100-02, 15, 120; 100-03, 4, 280.11; 100-03, 4, 280.12; 100-

04, 4, 240

Figure 43 Implant breast prosthesis.

❂ L8310 Truss, double with standard pads A

IOM: 100-02, 15, 120; 100-03, 4, 280.11; 100-03, 4, 280.12; 100-

04, 4, 240
❂ L8320 Truss, addition to standard pad, water pad A

IOM: 100-02, 15, 120; 100-03, 4, 280.11; 100-03, 4, 280.12; 100-

 04, 4, 240
❂ L8330 Truss, addition to standard pad, scrotal pad ♂ A

IOM: 100-02, 15, 120; 100-03, 4, 280.11; 100-03, 4, 280.12; 100-

04, 4, 240

Prosthetic Socks
❂ L8400 Prosthetic sheath, below knee, each A

IOM: 100-02, 15, 200

❂ L8410 Prosthetic sheath, above knee, each A

IOM: 100-02, 15, 200

❂ L8415 Prosthetic sheath, upper limb, each A

IOM: 100-02, 15, 200

✽ L8417 Prosthetic sheath/sock, including a gel cushion layer, below knee or
above knee, each A

Figure 44 (A) Nasal prosthesis, (B) Auricular prosthesis.

 ❂ L8420 Prosthetic sock, multiple ply, below knee, each A

IOM: 100-02, 15, 200

❂ L8430 Prosthetic sock, multiple ply, above knee, each A

IOM: 100-02, 15, 200

❂ L8435 Prosthetic sock, multiple ply, upper limb, each A

IOM: 100-02, 15, 200

❂ L8440 Prosthetic shrinker, below knee, each A

IOM: 100-02, 15, 200

❂ L8460 Prosthetic shrinker, above knee, each A

IOM: 100-02, 15, 200

❂ L8465 Prosthetic shrinker, upper limb, each A

IOM: 100-02, 15, 200

❂ L8470 Prosthetic sock, single ply, fitting, below knee, each A

IOM: 100-02, 15, 200

❂ L8480 Prosthetic sock, single ply, fitting, above knee, each A

IOM: 100-02, 15, 200

❂ L8485 Prosthetic sock, single ply, fitting, upper limb, each A

IOM: 100-02, 15, 200

Unlisted
✽ L8499 Unlisted procedure for miscellaneous prosthetic services A

Prosthetic Implants (L8500-L9900)

Larynx, Tracheoesophageal
❂ L8500 Artificial larynx, any type A

IOM: 100-02, 15, 120; 100-03, 1, 50.2; 100-04, 4, 240

❂ L8501 Tracheostomy speaking valve A

IOM: 100-03, 1, 50.4

✽ L8505 Artificial larynx replacement battery/accessory, any type A

✽ L8507 Tracheo-esophageal voice prosthesis, patient inserted, any type,

each A

✽ L8509 Tracheo-esophageal voice prosthesis, inserted by a licensed health

care provider, any type A

❂ L8510 Voice amplifier A

 IOM: 100-03, 1, 50.2
✽ L8511 Insert for indwelling tracheoesophageal prosthesis, with or without
valve, replacement only, each A

✽ L8512 Gelatin capsules or equivalent, for use with tracheoesophageal voice

prosthesis, replacement only, per 10 A

✽ L8513 Cleaning device used with tracheoesophageal voice prosthesis,

pipet, brush, or equal, replacement only, each A

✽ L8514 Tracheoesophageal puncture dilator, replacement only, each

A

✽ L8515 Gelatin capsule, application device for use with tracheoesophageal

voice prosthesis, each A
Breast
❂ L8600 Implantable breast prosthesis, silicone or equal ♀ N1 N

IOM: 100-02, 15, 120; 100-3, 2, 140.2

Bulking Agents
❂ L8603 Injectable bulking agent, collagen implant, urinary tract, 2.5 ml
syringe, includes shipping and necessary supplies N1 N

Bill on paper, acquisition cost invoice required

IOM: 100-03, 4, 280.1
✽ L8604 Injectable bulking agent, dextranomer/hyaluronic acid copolymer
implant, urinary tract, 1 ml, includes shipping and necessary
supplies N1 N

✽ L8605 Injectable bulking agent, dextranomer/hyaluronic acid copolymer

implant, anal canal, 1 ml, includes shipping and necessary supplies
N1 N

❂ L8606 Injectable bulking agent, synthetic implant, urinary tract, 1 ml

syringe, includes shipping and necessary supplies N1 N

Bill on paper, acquisition cost invoice required

IOM: 100-03, 4, 280.1
❂ L8607 Injectable bulking agent for vocal cord medialization, 0.1 ml,
includes shipping and necessary supplies N1 N

IOM: 100-03, 4, 280.1

Eye and Ear

✽ L8608 Miscellaneous external component, supply or accessory for use with
the Argus II retinal prosthesis system N

✽ L8609 Artificial cornea N1 N

❂ L8610 Ocular implant N1 N

IOM: 100-02, 15, 120

❂ L8612 Aqueous shunt N1 N

IOM: 100-02, 15, 120

Cross Reference Q0074
❂ L8613 Ossicula implant N1 N

IOM: 100-02, 15, 120

❂ L8614 Cochlear device, includes all internal and external components
N1 N

IOM: 100-02, 15, 120; 100-03, 1, 50.3

❂ L8615 Headset/headpiece for use with cochlear implant device,
replacement A

IOM: 100-03, 1, 50.3

❂ L8616 Microphone for use with cochlear implant device, replacement
A

IOM: 100-03, 1, 50.3

❂ L8617 Transmitting coil for use with cochlear implant device, replacement
A

IOM: 100-03, 1, 50.3

❂ L8618 Transmitter cable for use with cochlear implant device or auditory
osseointegrated device, replacement A

IOM: 100-03, 1, 50.3

❂ L8619 Cochlear implant, external speech processor and controller,
integrated system, replacement A

IOM: 100-03, 1, 50.3

✽ L8621 Zinc air battery for use with cochlear implant device and auditory
osseointegrated sound processors, replacement, each A

✽ L8622 Alkaline battery for use with cochlear implant device, any size,
replacement, each A

✽ L8623 Lithium ion battery for use with cochlear implant device speech
processor, other than ear level, replacement, each A

✽ L8624 Lithium ion battery for use with cochlear implant or auditory
osseointegrated device speech processor, ear level, replacement,
each A

❂ L8625 External recharging system for battery for use with cochlear implant
or auditory osseointegrated device, replacement only, each A

IOM: 103-03, PART 1, 50.3

❂ L8627 Cochlear implant, external speech processor, component,
replacement A

IOM: 103-03, PART 1, 50.3

❂ L8628 Cochlear implant, external controller component, replacement
A

IOM: 103-03, PART 1, 50.3

Transmitting coil and cable, integrated, for use with cochlear
 ❂ L8629 implant device, replacement A

IOM: 103-03, PART 1, 50.3

Hand and Foot

❂ L8630 Metacarpophalangeal joint implant N1 N

IOM: 100-02, 15, 120

❂ L8631 Metacarpal phalangeal joint replacement, two or more pieces, metal
(e.g., stainless steel or cobalt chrome), ceramic-like material (e.g.,
pyrocarbon), for surgical implantation (all sizes, includes entire
system) N1 N

IOM: 100-02, 15, 120

❂ L8641 Metatarsal joint implant N1 N

IOM: 100-02, 15, 120

❂ L8642 Hallux implant N1 N

May be billed by ambulatory surgical center or surgeon

IOM: 100-02, 15, 120
Cross Reference Q0073
❂ L8658 Interphalangeal joint spacer, silicone or equal, each
N1 N
IOM: 100-02, 15, 120
❂ L8659 Interphalangeal finger joint replacement, 2 or more pieces, metal
(e.g., stainless steel or cobalt chrome), ceramic-like material (e.g.,
pyrocarbon) for surgical implantation, any size N1 N

IOM: 100-02, 15, 120

Vascular
❂ L8670 Vascular graft material, synthetic, implant N1 N

IOM: 100-02, 15, 120

Neurostimulator
❂ L8679 Implantable neurostimulator, pulse generator, any type
N1 N
IOM: 100-03, 4, 280.4
L8680 Implantable neurostimulator electrode, each E1

Related CPT codes: 43647, 63650, 63655, 64553, 64555, 64560,

64561, 64565, 64573, 64575, 64577, 64580, 64581.
❂ L8681 Patient programmer (external) for use with implantable
 programmable neurostimulator pulse generator, replacement only
A

IOM: 100-03, 4, 280.4

❂ L8682 Implantable neurostimulator radiofrequency receiver
N1 N
IOM: 100-03, 4, 280.4
❂ L8683 Radiofrequency transmitter (external) for use with implantable
neurostimulator radiofrequency receiver A

IOM: 100-03, 4, 280.4

❂ L8684 Radiofrequency transmitter (external) for use with implantable
sacral root neurostimulator receiver for bowel and bladder
management, replacement A

IOM: 100-03, 4, 280.4

L8685 Implantable neurostimulator pulse generator, single array,
rechargeable, includes extension E1

Related CPT codes: 61885, 64590, 63685.

L8686 Implantable neurostimulator pulse generator, single array,
nonrechargeable, includes extension E1

Related CPT codes: 61885, 64590, 63685.

L8687 Implantable neurostimulator pulse generator, dual array,
rechargeable, includes extension E1

Related CPT codes: 64590, 63685, 61886.

L8688 Implantable neurostimulator pulse generator, dual array, non-
rechargeable, includes extension E1

Related CPT codes: 61885, 64590, 63685.

❂ L8689 External recharging system for battery (internal) for use with
implantable neurostimulator, replacement only A

IOM: 100-03, 4, 280.4

Figure 45 Metacarpophalangeal implant.

Miscellaneous Orthotic and Prosthetic Components, Services, and Supplies

✽ L8690 Auditory osseointegrated device, includes all internal and external
components N1 N

Related CPT codes: 69714, 69715, 69717, 69718.

✽ L8691 Auditory osseointegrated device, external sound processor, excludes
transducer/actuator, replacement only, each A

L8692 Auditory osseointegrated device, external sound processor, used

without osseointegration, body worn, includes headband or other
means of external attachment E1

Medicare Statute 1862(a)(7)

✽ L8693 Auditory osseointegrated device abutment, any length, replacement
only A

✽ L8694 Auditory osseointegrated device, transducer/actuator, replacement

only, each A

❂ L8695 External recharging system for battery (external) for use with
implantable neurostimulator, replacement only A

IOM: 100-03, 4, 280.4

❂ L8696 Antenna (external) for use with implantable diaphragmatic/phrenic
nerve stimulation device, replacement, each A

❂ L8698 Miscellaneous component, supply or accessory for use with total

artificial heart system A

✽ L8699 Prosthetic implant, not otherwise specified N1 N

✽ L8701 Elbow, wrist, hand device, powered. with single or double

upright(s), any type joint(s), includes microprocessor, sensors, all
components and accessories A

✽ L8702 Elbow, wrist, hand, finger device, powered, with single or double
upright(s), any type joint(s), includes microprocessor, sensors, all
components and accessories A

✽ L9900 Orthotic and prosthetic supply, accessory, and/or service component

of another HCPCS “L” code N1 N

OTHER MEDICAL SERVICES (M0000-M0301)

▶ ❂ M0001 Advancing cancer care MIPS value pathways M
▶ ❂ M0002 Optimal care for kidney health MIPS value pathways M

▶ ❂ M0003 Optimal care for patients with episodic neurological conditions

MIPS value pathways M

▶ ❂ M0004 Supportive care for neurodegenerative conditions MIPS value

pathways M

▶ ❂ M0005 Promoting wellness MIPS value pathways M

M0075 Cellular therapy E1

M0076 Prolotherapy E1

Prolotherapy stimulates production of new ligament tissue. Not

covered by Medicare.
M0100 Intragastric hypothermia using gastric freezing E1

M0201 Covid-19 vaccine administration inside a patient’s home; reported

only once per individual home per date of service when only covid-
19 vaccine administration is performed at the patient’s home S

▶ M0222 Intravenous injection, bebtelovimab, includes injection and post

administration monitoring
▶ M0223 Intravenous injection, bebtelovimab, includes injection and post
administration monitoring in the home or residence; this includes a
beneficiary’s home that has been made provider-based to the
hospital during the covid-19 public health emergency
M0240 Intravenous infusion or subcutaneous injection, casirivimab and
imdevimab includes infusion or injection, and post administration
monitoring, subsequent repeat doses S

M0241 Intravenous infusion or subcutaneous injection, casirivimab and

imdevimab includes infusion or injection, and post administration
monitoring in the home or residence; this includes a beneficiary’s
home that has been made provider-based to the hospital during the
covid-19 public health emergency, subsequent repeat doses S

M0243 Intravenous infusion or subcutaneous injection, casirivimab and

imdevimab includes infusion and post administration monitoring S
Coding Clinic: 2022, Q2, P9
M0244 Intravenous infusion or subcutaneous injection, casirivimab and
imdevimab includes infusion or injection, and post administration
monitoring in the home or residence; this includes a beneficiary’s
home that has been made provider-based to the hospital during the
covid-19 public health emergency S
M0245 Intravenous infusion, bamlanivimab and etesevimab, includes
infusion and post administration monitoring S

M0246 AIntravenous infusion, bamlanivimab and etesevimab, includes

infusion and post administration monitoring in the home or
residence; this includes a beneficiary’s home that has been made
provider based to the hospital during the covid 19 public health
emergency S

M0247 Intravenous infusion, sotrovimab, includes infusion and post

administration monitoring S

M0248 Intravenous infusion, sotrovimab, includes infusion and post

administration monitoring in the home or residence; this includes a
beneficiary’s home that has been made provider-based to the
hospital during the covid-19 public health emergency S

M0249 Intravenous infusion, tocilizumab, for hospitalized adults and

pediatric patients (2 years of age and older) with covid-19 who are
receiving systemic corticosteroids and require supplemental oxygen,
non-invasive or invasive mechanical ventilation, or extracorporeal
membrane oxygenation (ecmo) only, includes infusion and post
administration monitoring, first dose S

M0250 Intravenous infusion, tocilizumab, for hospitalized adults and

pediatric patients (2 years of age and older) with covid-19 who are
receiving systemic corticosteroids and require supplemental oxygen,
non-invasive or invasive mechanical ventilation, or extracorporeal
membrane oxygenation (ecmo) only, includes infusion and post
administration monitoring, second dose S

M0300 IV chelation therapy (chemical endarterectomy) E1

M0301 Fabric wrapping of abdominal aneurysm E1

Treatment for abdominal aneurysms that involves wrapping

aneurysms with cellophane or fascia lata. Fabric wrapping of
abdominal aneurysms is not a covered Medicare procedure.
✽ M1003 TB screening performed and results interpreted within twelve
months prior to initiation of first-time biologic and/or immune
response modifier therapy M

✽ M1004 Documentation of medical reason for not screening for TB or

interpreting results (i.e., patient positive for TB and documentation
of past treatment; patient who has recently completed a course of
anti-TB therapy) M

✽ M1005 TB screening not performed or results not interpreted, reason not

 given M

✽ M1006 Disease activity not assessed, reason not given M

✽ M1007 >=50% of total number of a patient’s outpatient RA encounters

assessed M

✽ M1008 <50% of total number of a patient’s outpatient RA encounters

assessed M

✽ M1009 Discharge/discontinuation of the episode of care documented in the

medical record M

✽ M1010 Discharge/discontinuation of the episode of care documented in the

medical record M

✽ M1011 Discharge/discontinuation of the episode of care documented in the

medical record M

✽ M1012 Discharge/discontinuation of the episode of care documented in the

medical record M

✽ M1013 Discharge/discontinuation of the episode of care documented in the

medical record M

✽ M1014 Discharge/discontinuation of the episode of care documented in the

medical record M

✽ M1016 Female patients unable to bear children M

M1017 Patient admitted to palliative care services ✖

✽ M1018 Patients with an active diagnosis or history of cancer (except basal
cell and squamous cell skin carcinoma), patients who are heavy
tobacco smokers, lung cancer screening patients M

✽ M1019 Adolescent patients 12 to 17 years of age with major depression or

dysthymia who reached remission at twelve months as demonstrated
by a twelve month (+/-60 days) PHQ-9 or PHQ-9m score of less
than five M

✽ M1020 Adolescent patients 12 to 17 years of age with major depression or

dysthymia who did not reach remission at twelve months as
demonstrated by a twelve month (+/-60 days) PHQ-9 or PHQ-9m
score of less than 5. Either PHQ-9 or PHQ-9m score was not
assessed or is greater than or equal to 5 M

✽ M1021 Patient had only urgent care visits during the performance period
M
✽ M1027 Imaging of the head (CT or MRI) was obtained M

✽ M1028 Documentation of patients with primary headache diagnosis and

imaging other than CT or MRI obtained M
✽ M1029 Imaging of the head (CT or MRI) was not obtained, reason not
given M

✽ M1032 Adults currently taking pharmacotherapy for OUD M

✽ M1034 Adults who have at least 180 days of continuous pharmacotherapy

with a medication prescribed for OUD without a gap of more than
seven days M

✽ M1035 Adults who are deliberately phased out of medication assisted

treatment (MAT) prior to 180 days of continuous treatment M

✽ M1036 Adults who have not had at least 180 days of continuous
pharmacotherapy with a medication prescribed for oud without a
gap of more than seven days M

✽ M1037 Patients with a diagnosis of lumbar spine region cancer at the time
of the procedure M

✽ M1038 Patients with a diagnosis of lumbar spine region fracture at the time
of the procedure M

✽ M1039 Patients with a diagnosis of lumbar spine region infection at the

time of the procedure M

✽ M1040 Patients with a diagnosis of lumbar idiopathic or congenital

scoliosis M

✽ M1041 Patient had cancer, acute fracture or infection related to the lumbar
spine or patient had neuromuscular, idiopathic or congenital lumbar
scoliosis M

✽ M1043 Functional status was not measured by the Oswestry Disability

Index (ODI version 2.1a) at one year (9 to 15 months)
postoperatively M

✽ M1045 Functional status measured by the Oxford Knee Score (OKS) at one
year (9 to 15 months) postoperatively was greater than or equal to
37 or knee injury and osteoarthritis outcome score joint replacement
(Koos, jr.) was greater than or equal to 71 M

✽ M1046 Functional status the Oxford Knee Score (OKS) at one year (9 to 15
months) postoperatively was less than 37 or the knee injury and
osteoarthritis outcome score joint replacement (Koos, jr.) was less
than 71 postoperatively M

✽ M1049 Functional status was not measured by the Oswestry Disability

Index (ODI version 2.1a) at three months (6 to 20 weeks)
postoperatively M

✽ M1051 Patient had cancer, acute fracture or infection related to the lumbar
spine or patient had neuromuscular, idiopathic or congenital lumbar
 scoliosis M

✽ M1052 Leg pain was not measured by the Visual Analog Scale (VAS) or
numeric pain scale at one year (9 to 15 months) postoperatively
M
✽ M1054 Patient had only urgent care visits during the performance period
M
✽ M1055 Aspirin or another antiplatelet therapy used M

✽ M1056 Prescribed anticoagulant medication during the performance period,

history of GI bleeding, history of intracranial bleeding, bleeding
disorder and specific provider documented reasons: allergy to
aspirin or anti-platelets, use of nonsteroidal anti-inflammatory
agents, drug-drug interaction, uncontrolled hypertension >180/110
mmhg or gastroesophageal reflux disease M

✽ M1057 Aspirin or another antiplatelet therapy not used, reason not given
M
✽ M1058 Patient was a permanent nursing home resident at any time during
the performance period M

✽ M1059 Patient was in hospice or receiving palliative care at any time during
the performance period M

✽ M1060 Patient died prior to the end of the performance period M

✽ M1067 Hospice services for patient provided any time during the
measurement period M

✽ M1068 Adults who are not ambulatory M

✽ M1069 Patient screened for future fall risk M

✽ M1070 Patient not screened for future fall risk, reason not given M

M1071 Patient had any additional spine procedures performed on the ✖

same date as the lumbar discectomy/laminotomy
✽ M1072 Radiation therapy for anal cancer under the radiation oncology
model, 90 day episode, professional component
✽ M1073 Radiation therapy for anal cancer under the radiation oncology
model, 90 day episode, technical component

✽ M1074 Radiation therapy for bladder cancer under the radiation oncology
model, 90 day episode, professional component
✽ M1075 Radiation therapy for bladder cancer under the radiation oncology
model, 90 day episode, technical component
✽ M1076 Radiation therapy for bone metastases under the radiation oncology
model, 90 day episode, professional component
✽ M1077 Radiation therapy for bone metastases under the radiation oncology
model, 90 day episode, technical component
✽ M1078 Radiation therapy for brain metastases under the radiation oncology
model, 90 day episode, professional component
✽ M1079 Radiation therapy for brain metastases under the radiation oncology
model, 90 day episode, technical component
✽ M1080 Radiation therapy for breast cancer under the radiation oncology
model, 90 day episode, professional component

✽ M1081 Radiation therapy for breast cancer under the radiation oncology
model, 90 day episode, technical component
✽ M1082 Radiation therapy for cervical cancer under the radiation oncology
model, 90 day episode, professional component
✽ M1083 Radiation therapy for cervical cancer under the radiation oncology
model, 90 day episode, technical component
✽ M1084 Radiation therapy for cns tumors under the radiation oncology
model, 90 day episode, professional component
✽ M1085 Radiation therapy for cns tumors under the radiation oncology
model, 90 day episode, technical component
✽ M1086 Radiation therapy for colorectal cancer under the radiation oncology
model, 90 day episode, professional component
✽ M1087 Radiation therapy for colorectal cancer under the radiation oncology
model, 90 day episode, technical component
✽ M1088 Radiation therapy for head and neck cancer under the radiation
oncology model, 90 day episode, professional component
✽ M1089 Radiation therapy for head and neck cancer under the radiation
oncology model, 90 day episode, technical component
✽ M1094 Radiation therapy for lung cancer under the radiation oncology
model, 90 day episode, professional component
✽ M1095 Radiation therapy for lung cancer under the radiation oncology
model, 90 day episode, technical component
✽ M1096 Radiation therapy for lymphoma under the radiation oncology
model, 90 day episode, professional component
✽ M1097 Radiation therapy for lymphoma under the radiation oncology
model, 90 day episode, technical component
✽ M1098 Radiation therapy for pancreatic cancer under the radiation
oncology model, 90 day episode, professional component
✽ M1099 Radiation therapy for pancreatic cancer under the radiation
oncology model, 90 day episode, technical component
✽ M1100 Radiation therapy for prostate cancer under the radiation oncology
model, 90 day episode, professional component
✽ M1101 Radiation therapy for prostate cancer under the radiation oncology
model, 90 day episode, technical component
✽ M1102 Radiation therapy for upper GI cancer under the radiation oncology
model, 90 day episode, professional componentt
✽ M1103 Radiation therapy for upper GI cancer under the radiation oncology
model, 90 day episode, technical component
✽ M1104 Radiation therapy for uterine cancer under the radiation oncology
model, 90 day episode, professional component
✽ M1105 Radiation therapy for uterine cancer under the radiation oncology
model, 90 day episode, technical component
✽ M1106 The start of an episode of care documented in the medical record
M
✽ M1107 Documentation stating patient has a diagnosis of a degenerative
neurological condition such as ALS, MS, or Parkinson’s diagnosed
at any time before or during the episode of care M

✽ M1108 Ongoing care not clinically indicated because the patient needed a
home program only, referred to another provider or facility,
consultation only, as documented in the medical record M

✽ M1109 Ongoing care not medically possible because the patient was
discharged early due to specific medical events, documented in the
medical record, such as the patient became hospitalized or
scheduled for surgery M

✽ M1110 Ongoing care not possible because the patient self-discharged early
(e.g., financial or insurance reasons, transportation problems, or
reason unknown) M

✽ M1111 The start of an episode of care documented in the medical record

M
✽ M1112 Documentation stating patient has a diagnosis of a degenerative
neurological condition such as ALS, MS, or Parkinson’s diagnosed
at any time before or during the episode of care M

✽ M1113 Ongoing care not clinically indicated because the patient needed a
home program only, referred to another provider or facility,
consultation only, as documented in the medical record M

✽ M1114 Ongoing care not medically possible because the patient was
discharged early due to specific medical events, documented in the
 medical record such as the patient becomes hospitalized or
scheduled for surgery M

✽ M1115 Ongoing care not possible because the patient self-discharged early
(e.g., financial or insurance reasons, transportation problems, or
reason unknown) M

✽ M1116 The start of an episode of care documented in the medical record

M
✽ M1117 Documentation stating patient has a diagnosis of a degenerative
neurological condition such as ALS, MS, or Parkinson’s diagnosed
at any time before or during the episode of care M

✽ M1118 Ongoing care not clinically indicated because the patient needed a
home program only, referred to another provider or facility,
consultation only, as documented in the medical record M

✽ M1119 Ongoing care not medically possible because the patient was
discharged early due to specific medical events, documented in the
medical record such as the patient becomes hospitalized or
scheduled for surgery M

✽ M1120 Ongoing care not possible because the patient self-discharged early
(e.g., financial or insurance reasons, transportation problems, or
reason unknown) M

✽ M1121 The start of an episode of care documented in the medical record

M
✽ M1122 Documentation stating patient has a diagnosis of a degenerative
neurological condition such as ALS, MS, or Parkinson’s diagnosed
at any time before or during the episode of care M

✽ M1123 Ongoing care not clinically indicated because the patient needed a
home program only, referred to another provider or facility,
consultation only, as documented in the medical record M

✽ M1124 Ongoing care not medically possible because the patient was
discharged early due to specific medical events, documented in the
medical record such as the patient becomes hospitalized or
scheduled for surgery M

✽ M1125 Ongoing care not possible because the patient self-discharged early
(e.g., financial or insurance reasons, transportation problems, or
reason unknown) M

✽ M1126 The start of an episode of care documented in the medical record

M
✽ M1127 Documentation stating patient has a diagnosis of a degenerative
neurological condition such as ALS, MS, or Parkinson’s diagnosed
at any time before or during the episode of care M
✽ M1128 Ongoing care not clinically indicated because the patient needed a
home program only, referred to another provider or facility,
consultation only, as documented in the medical record M

✽ M1129 Ongoing care not medically possible because the patient was
discharged early due to specific medical events, documented in the
medical record such as the patient becomes hospitalized or
scheduled for surgery M

✽ M1130 Ongoing care not possible because the patient self-discharged early
(e.g., financial or insurance reasons, transportation problems, or
reason unknown) M

✽ M1131 Documentation stating patient has a diagnosis of a degenerative

neurological condition such as ALS, MS, or Parkinson’s diagnosed
at any time before or during the episode of care M

✽ M1132 Ongoing care not clinically indicated because the patient needed a
home program only, referred to another provider or facility,
consultation only, as documented in the medical record M

✽ M1133 Ongoing care not due to specific medical events, documented in the
medical record such as the patient becomes hospitalized or
scheduled for surgery M

✽ M1134 Ongoing care not possible because the patient self-discharged early
(e.g., financial or insurance reasons, transportation problems, or
reason unknown) M

✽ M1135 The start of an episode of care documented in the medical record

M
✽ M1141 Functional status was not measured by the Oxford Knee Score
(OKS) or the knee injury and osteoarthritis outcome score joint
replacement (Koos, jr.) at one year (9 to 15 months) postoperatively
M
✽ M1142 Emergent cases M

✽ M1143 Initiated episode of rehabilitation therapy, medical, or chiropractic

care for neck impairment M

✽ M1145 Most favored nation (MFN) model drug add-on amount, per dose,
(do not bill with line items that have the JW modifier) K

✽ M1146 Ongoing care not clinically indicated because the patient needed a
home program only, referral to another provider or facility, or
consultation only, as documented in the medical record M

✽ M1147 Ongoing care not medically possible because the patient was
discharged early due to specific medical events, documented in the
 medical record, such as the patient became hospitalized or
scheduled for surgery M

✽ M1148 Ongoing care not possible because the patient self-discharged early
(e.g., financial or insurance reasons, transportation problems, or
reason unknown) M

✽ M1149 Patient unable to complete the neck fs prom at initial evaluation

and/or discharge due to blindness, illiteracy, severe mental
incapacity or language incompatibility, and an adequate proxy is not
available M

▶ ❂ M1150 Left ventricular ejection fraction (LVEF) less than or equal to 40%
or documentation of moderately or severely depressed left
ventricular systolic function M

▶ ❂ M1151 Patients with a history of heart transplant or with a left ventricular

assist device (LVAD) M

▶ ❂ M1152 Patients with a history of heart transplant or with a left ventricular

assist device (LVAD) M

▶ ❂ M1153 Patient with diagnosis of osteoporosis on date of encounter M

▶ ❂ M1154 Hospice services provided to patient any time during the

measurement period M

▶ ❂ M1155 Patient had anaphylaxis due to the pneumococcal vaccine any time
during or before the measurement period M

▶ ❂ M1156 Patient received active chemotherapy any time during the

measurement period M

▶ ❂ M1157 Patient received bone marrow transplant any time during the
measurement period M

▶ ❂ M1158 Patient had history of immunocompromising conditions prior to or

during the measurement period M

▶ ❂ M1159 Hospice services provided to patient any time during the

measurement period M

▶ ❂ M1160 Patient had anaphylaxis due to the meningococcal vaccine any time
on or before the patient’s 13th birthday M

▶ ❂ M1161 Patient had anaphylaxis due to the tetanus, diphtheria, or pertussis

vaccine any time on or before the patient’s 13th birthday M

▶ ❂ M1162 Patient had encephalitis due to the tetanus, diphtheria, or pertussis

vaccine any time on or before the patient’s 13th birthday M

▶ ❂ M1163 Patient had anaphylaxis due to the HPV vaccine any time on or
 before the patient’s 13th birthday M

▶ ❂ M1164 Patients with dementia any time during the patient’s history through
the end of the measurement period M

▶ ❂ M1165 Patients who use hospice services any time during the measurement
period
▶ ❂ M1166 Pathology report for tissue specimens produced from wide local
excisions or re-excisions M

▶ ❂ M1167 In hospice or using hospice services during the measurement period

▶ ❂ M1168 Patient received an influenza vaccine on or between July 1 of the
year prior to the measurement period and June 30 of the
measurement period M

▶ ❂ M1169 Documentation of medical reason(s) for not administering influenza

vaccine (e.g., prior anaphylaxis due to the influenza vaccine) M

▶ ❂ M1170 Patient did not receive an influenza vaccine on or between July 1 of

the year prior to the measurement period and June 30 of the
measurement period M

▶ ❂ M1171 Patient received at least one TD vaccine or one Tdap vaccine

between nine years prior to the encounter and the end of the
measurement period M

▶ ❂ M1172 Documentation of medical reason(s) for not administering TD or

Tdap vaccine (e.g., prior anaphylaxis due to the TD or Tdap vaccine
or history of encephalopathy within seven days after a previous dose
of a TD-containing vaccine) M

▶ ❂ M1173 Patient did not receive at least one TD vaccine or one Tdap vaccine
between nine years prior to the encounter and the end of the
measurement period M

▶ ❂ M1174 Patient received at least one dose of the herpes zoster live vaccine or
two doses of the herpes zoster recombinant vaccine (at least 28 days
apart) anytime on or after the patient’s 50th birthday before or
during the measurement period M

▶ ❂ M1175 Documentation of medical reason(s) for not administering zoster

vaccine (e.g., prior anaphylaxis due to the zoster vaccine) M

▶ ❂ M1176 Patient did not receive at least one dose of the herpes zoster live
vaccine or two doses of the herpes zoster recombinant vaccine (at
least 28 days apart) anytime on or after the patient’s 50th birthday
before or during the measurement period M

▶ ❂ M1177 Patient received any pneumococcal conjugate or polysaccharide

 vaccine on or after their 60th birthday and before the end of the
measurement period M

▶ ❂ M1178 Documentation of medical reason(s) for not administering

pneumococcal vaccine (e.g., prior anaphylaxis due to the
pneumococcal vaccine) M

▶ ❂ M1179 Patient did not receive any pneumococcal conjugate or

polysaccharide vaccine, on or after their 60th birthday and before or
during measurement period M

▶ ❂ M1180 Patients on immune checkpoint inhibitor therapy M

▶ ❂ M1181 Grade 2 or above diarrhea and/or grade 2 or above colitis M

▶ ❂ M1182 Patients not eligible due to pre-existing inflammatory bowel disease

(IBD) (e.g., ulcerative colitis, Crohn’s disease) M

▶ ❂ M1183 Documentation of immune checkpoint inhibitor therapy held and

corticosteroids or immunosuppressants prescribed or administered
M
▶ ❂ M1184 Documentation of medical reason(s) for not prescribing or
administering corticosteroid or immunosuppressant treatment (e.g.,
allergy, intolerance, infectious etiology, pancreatic insufficiency,
hyperthyroidism, prior bowel surgical interventions, Celiac disease,
receiving other medication, awaiting diagnostic workup results for
alternative etiologies, other medical reasons/contraindication) M

▶ ❂ M1185 Documentation of immune checkpoint inhibitor therapy not held

and/or corticosteroids or immunosuppressants prescribed or
administered was not performed, reason not given M

▶ ❂ M1186 Patients who have an order for or are receiving hospice or palliative
care M

▶ ❂ M1187 Patients with a diagnosis of end stage renal disease (ESRD) M

▶ ❂ M1188 Patients with a diagnosis of chronic kidney disease (CKD) stage 5

M
▶ ❂ M1189 Documentation of a kidney health evaluation defined by an
estimated glomerular filtration rate (EGFR) and urine albumin-
creatinine ratio (UACR) performed M

▶ ❂ M1190 Documentation of a kidney health evaluation was not performed or

defined by an estimated glomerular filtration rate (EGFR) and urine
albumin-creatinine ratio (UACR) M

▶ ❂ M1191 Hospice services provided to patient any time during the

measurement period M

Patients with an existing diagnosis of squamous cell carcinoma of

▶ ❂ M1192 the esophagus M

▶ ❂ M1193 Surgical pathology reports that contain impression or conclusion of

or recommendation for testing of MMR by immunohistochemistry,
MSI by DNAbased testing status, or both M

▶ ❂ M1194 Documentation of medical reason(s) surgical pathology reports did

not contain impression or conclusion of or recommendation for
testing of MMR by immunohistochemistry, MSI by DNAbased
testing status, or both tests were not included (e.g., patient will not
be treated with checkpoint inhibitor therapy, no residual carcinoma
is present in the sample [tissue exhausted or status post neoadjuvant
treatment], insufficient tumor for testing) M

▶ ❂ M1195 Surgical pathology reports that do not contain impression or

conclusion of or recommendation for testing of MMR by
immunohistochemistry, MSI by DNAbased testing status, or both,
reason not given M

▶ ❂ M1196 Initial (index visit) numeric rating scale (NRS), visual rating scale
(VRS), or itchyquant assessment score of greater than or equal to 4
M
▶ ❂ M1197 Itch severity assessment score is reduced by 2 or more points from
the initial (index) assessment score to the follow-up visit score M

▶ ❂ M1198 Itch severity assessment score was not reduced by at least 2 points
from initial (index) score to the follow-up visit score or assessment
was not completed during the follow-up encounter M

▶ ❂ M1199 Patients receiving RRT M

▶ ❂ M1200 Ace inhibitor (ace-i) or ARB therapy prescribed during the

measurement period M

▶ ❂ M1201 Documentation of medical reason(s) for not prescribing ace

inhibitor (ace-i) or ARB therapy during the measurement period
(e.g., pregnancy, history of angioedema to ace-i, other allergy to
ace-i and ARB, hyperkalemia, or history of hyperkalemia while on
ace-i or ARB therapy, acute kidney injury due to ace-i or ARB
therapy), other medical reasons) M

▶ ❂ M1202 Documentation of patient reason(s) for not prescribing ace inhibitor

or ARB therapy during the measurement period, (e.g., patient
declined, other patient reasons) M

▶ ❂ M1203 Ace inhibitor or ARB therapy not prescribed during the

measurement period, reason not given M

Initial (index visit) numeric rating scale (NRS), visual rating scale
 ▶ ❂ M1204 (VRS), or itchyquant assessment score of greater than or equal to 4
M

▶ ❂ M1205 Itch severity assessment score is reduced by 2 or more points from

the initial (index) assessment score to the follow-up visit score M

▶ ❂ M1206 Itch severity assessment score was not reduced by at least 2 points
from initial (index) score to the follow-up visit score or assessment
was not completed during the follow-up encounter M

▶ ❂ M1207 Number of patients screened for food insecurity, housing instability,

transportation needs, utility difficulties, and interpersonal safety M
▶ ❂ M1208 Number of patients not screened for food insecurity, housing
instability, transportation needs, utility difficulties, and interpersonal
safety M

▶ ❂ M1209 At least two orders for high-risk medications from the same drug
class, (table 4), not ordered M

▶ ❂ M1210 At least two orders for high-risk medications from the same drug
class, (table 4), not ordered M

LABORATORY SERVICES (P0000-P9999)

Chemistry and Toxicology Tests
❂ P2028 Cephalin floculation, blood A

This code appears on a CMS list of codes that represent obsolete

and unreliable tests and procedures. Verify before reporting.
IOM: 100-03, 4, 300.1
❂ P2029 Congo red, blood A

This code appears on a CMS list of codes that represent obsolete

and unreliable tests and procedures. Verify before reporting.
IOM: 100-03, 4, 300.1
P2031 Hair analysis (excluding arsenic) E1

IOM: 100-03, 4, 300.1

❂ P2033 Thymol turbidity, blood A

This code appears on a CMS list of codes that represent obsolete

and unreliable tests and procedures. Verify before reporting.
IOM: 100-03, 4, 300.1
❂ P2038 Mucoprotein, blood (seromucoid) (medical necessity procedure)
 A

This code appears on a CMS list of codes that represent obsolete

and unreliable tests and procedures. Verify before reporting.
IOM: 100-03, 4, 300.1

Pathology Screening Tests

❂ P3000 Screening Papanicolaou smear, cervical or vaginal, up to three
smears, by technician under physician supervision ♀ A

Co-insurance and deductible waived

Assign for Pap smear ordered for screening purposes only,
conventional method, performed by technician
IOM: 100-03, 3, 190.2,
Laboratory Certification: Cytology
❂ P3001 Screening Papanicolaou smear, cervical or vaginal, up to three
smears, requiring interpretation by physician ♀ B

Co-insurance and deductible waived

Report professional component for Pap smears requiring physician
interpretation. There are CPT codes assigned for diagnostic Paps,
such as, 88141; HCPCS are for screening Paps.
IOM: 100-03, 3, 190.2
Laboratory Certification: Cytology

Microbiology Tests
P7001 Culture, bacterial, urine; quantitative, sensitivity study E1

Cross Reference CPT

Laboratory Certification: Bacteriology

Miscellaneous Pathology
❂ P9010 Blood (whole), for transfusion, per unit R

Blood furnished on an outpatient basis, subject to Medicare Part B

blood deductible; applicable to first 3 pints of whole blood or
equivalent units of packed red cells in calendar year
IOM: 100-01, 3, 20.5; 100-02, 1, 10
❂ P9011 Blood, split unit R

Reports all splitting activities of any blood component

 IOM: 100-01, 3, 20.5; 100-02, 1, 10
❂ P9012 Cryoprecipitate, each unit R

IOM: 100-01, 3, 20.5; 100-02, 1, 10

❂ P9016 Red blood cells, leukocytes reduced, each unit R

IOM: 100-01, 3, 20.5; 100-02, 1, 10

❂ P9017 Fresh frozen plasma (single donor), frozen within 8 hours of
collection, each unit R

IOM: 100-01, 3, 20.5; 100-02, 1, 10

❂ P9019 Platelets, each unit R

IOM: 100-01, 3, 20.5; 100-02, 1, 10

❂ P9020 Platelet rich plasma, each unit R

IOM: 100-01, 3, 20.5; 100-02, 1, 10

❂ P9021 Red blood cells, each unit R

IOM: 100-01, 3, 20.5; 100-02, 1, 10

❂ P9022 Red blood cells, washed, each unit R

IOM: 100-01, 3, 20.5; 100-02, 1, 10

❂ P9023 Plasma, pooled multiple donor, solvent/detergent treated, frozen,
each unit R

IOM: 100-01, 3, 20.5; 100-02, 1, 10

❂ P9025 Plasma, cryoprecipitate reduced, pathogen reduced, each unit R

❂ P9026 Cryoprecipitated fibrinogen complex, pathogen reduced, each unit

R
❂ P9031 Platelets, leukocytes reduced, each unit R

IOM: 100-01, 3, 20.5; 100-02, 1, 10

❂ P9032 Platelets, irradiated, each unit R

IOM: 100-01, 3, 20.5; 100-02, 1, 10

❂ P9033 Platelets, leukocytes reduced, irradiated, each unit R

IOM: 100-01, 3, 20.5; 100-02, 1, 10

❂ P9034 Platelets, pheresis, each unit R

IOM: 100-01, 3, 20.5; 100-02, 1, 10

❂ P9035 Platelets, pheresis, leukocytes reduced, each unit R

IOM: 100-01, 3, 20.5; 100-02, 1, 10

❂ P9036 Platelets, pheresis, irradiated, each unit R

IOM: 100-01, 3, 20.5; 100-02, 1, 10

❂ P9037 Platelets, pheresis, leukocytes reduced, irradiated, each unit
 IOM: 100-01, 3, 20.5; 100-02, 1, 10 R

❂ P9038 Red blood cells, irradiated, each unit R

IOM: 100-01, 3, 20.5; 100-02, 1, 10

❂ P9039 Red blood cells, deglycerolized, each unit R

IOM: 100-01, 3, 20.5; 100-02, 1, 10

❂ P9040 Red blood cells, leukocytes reduced, irradiated, each unit
R
IOM: 100-01, 3, 20.5; 100-02, 1, 10
✽ P9041 Infusion, albumin (human), 5%, 50 ml K2 K

❂ P9043 Infusion, plasma protein fraction (human), 5%, 50 ml R

IOM: 100-01, 3, 20.5; 100-02, 1, 10

❂ P9044 Plasma, cryoprecipitate reduced, each unit R

IOM: 100-01, 3, 20.5; 100-02, 1, 10

✽ P9045 Infusion, albumin (human), 5%, 250 ml K2 K

✽ P9046 Infusion, albumin (human), 25%, 20 ml K2 K

✽ P9047 Infusion, albumin (human), 25%, 50 ml K2 K

✽ P9048 Infusion, plasma protein fraction (human), 5%, 250 ml R

✽ P9050 Granulocytes, pheresis, each unit E2

❂ P9051 Whole blood or red blood cells, leukocytes reduced, CMV-negative,

each unit R

Medicare Statute 1833(t)

❂ P9052 Platelets, HLA-matched leukocytes reduced, apheresis/pheresis,
each unit R

Medicare Statute 1833(t)

❂ P9053 Platelets, pheresis, leukocytes reduced, CMV-negative, irradiated,
each unit R

Freezing and thawing are reported separately, see Transmittal 1487

(Hospital outpatient)
Medicare Statute 1833(t)
❂ P9054 Whole blood or red blood cells, leukocytes reduced, frozen,
deglycerol, washed, each unit R

Medicare Statute 1833(t)

❂ P9055 Platelets, leukocytes reduced, CMV-negative, apheresis/pheresis,
each unit R

Medicare Statute 1833(t)

❂ P9056 Whole blood, leukocytes reduced, irradiated, each unit R
 Medicare Statute 1833(t)
❂ P9057 Red blood cells, frozen/deglycerolized/washed, leukocytes reduced,
irradiated, each unit R

Medicare Statute 1833(t)

❂ P9058 Red blood cells, leukocytes reduced, CMV-negative, irradiated, each
unit R

Medicare Statute 1833(t)

❂ P9059 Fresh frozen plasma between 8-24 hours of collection, each unit
R

Medicare Statute 1833(t)

❂ P9060 Fresh frozen plasma, donor retested, each unit R

Medicare Statute 1833(t)

❂ P9070 Plasma, pooled multiple donor, pathogen reduced, frozen, each unit
R

Medicare Statute 1833(T)

❂ P9071 Plasma (single donor), pathogen reduced, frozen, each unit
R
IOM: 100-01, 3, 20.5; 100-02, 1, 10
Medicare Statute 1833T
❂ P9073 Platelets, pheresis, pathogen-reduced, each unit R

IOM: 100-01, 3, 20.5; 100-02, 1, 10

Medicare Statute 1833T
✽ P9099 Blood component or product not otherwise classified E2

❂ P9100 Pathogen(s) test for platelets S

IOM: 100-03, 4, 300.1

Travel Allowance for Specimen Collection

❂ P9603 Travel allowance one way in connection with medically necessary
laboratory specimen collection drawn from home bound or nursing
home bound patient; prorated miles actually traveled A

Fee for clinical laboratory travel (P9603) is $1.025 per mile for
CY2015.
IOM: 100-04, 16, 60
❂ P9604 Travel allowance one way in connection with medically necessary
laboratory specimen collection drawn from home bound or nursing
home bound patient; prorated trip charge A

For CY2010, the fee for clinical laboratory travel is $10.30 per flat
 rate trip for CY2015.
IOM: 100-04, 16, 60

Catheterization for Specimen Collection

❂ P9612 Catheterization for collection of specimen, single patient, all places
of service A

NCCI edits indicate that when 51701 is comprehensive or is a

Column 1 code, P9612 cannot be reported. When the catheter
insertion is a component of another procedure, do not report straight
catheterization separately.
IOM: 100-04, 16, 60
Coding Clinic: 2007, Q3, P7
❂ P9615 Catheterization for collection of specimen(s) (multiple patients)
N

IOM: 100-04, 16, 60

TEMPORARY CODES ASSIGNED BY CMS (Q0000-Q9999)

Cardiokymography
❂ Q0035 Cardiokymography Q1

Report modifier 26 if professional component only

IOM: 100-03, 1, 20.24

Infusion Therapy
❂ Q0081 Infusion therapy, using other than chemotherapeutic drugs, per visit
B

IV piggyback only assigned one time per patient encounter per day.
Report for hydration or the intravenous administration of antibiotics,
antiemetics, or analgesics. Bill on paper. Requires a report.
IOM: 100-03, 4, 280.14
Coding Clinic: 2004, Q2, P11; Q1, P5, 8; 2002, Q2, P10; Q1, P7

Chemotherapy Administration
✽ Q0083 Chemotherapy administration by other than infusion technique only
(e.g., subcutaneous, intramuscular, push), per visit B
Coding Clinic: 2002, Q1, P7
 ❂ Q0084 Chemotherapy administration by infusion technique only, per visit
B
IOM: 100-03, 4, 280.14
Coding Clinic: 2004, Q2, P11; 2002, Q1, P7
✽ Q0085 Chemotherapy administration by both infusion technique and other
technique(s) (e.g., subcutaneous, intramuscular, push), per visit
B
Coding Clinic: 2002, Q1, P7

Smear Preparation
❂ Q0091 Screening Papanicolaou smear; obtaining, preparing and
conveyance of cervical or vaginal smear to laboratory ♀ S

Medicare does not cover comprehensive preventive medicine

services; however, services described by G0101 and Q0091 (only
for Medicare patients) are covered. Includes the services necessary
to procure and transport the specimen to the laboratory.
IOM: 100-03, 3, 190.2
Coding Clinic: 2002, Q4, P8

Portable X-ray Setup

❂ Q0092 Set-up portable x-ray equipment N

IOM: 100-04, 13, 90

Miscellaneous Lab Services

✽ Q0111 Wet mounts, including preparations of vaginal, cervical or skin
specimens A

Laboratory Certification: Bacteriology, My cology, Parasitology

✽ Q0112 All potassium hydroxide (KOH) preparations A

Laboratory Certification: Mycology

✽ Q0113 Pinworm examinations A

Laboratory Certification: Parasitology

✽ Q0114 Fern test ♀ A

Laboratory Certification: Routine chemistry

✽ Q0115 Post-coital direct, qualitative examinations of vaginal or cervical
mucous ♀ A

Laboratory Certification: Hematology

Drugs
✽ Q0138 Injection, ferumoxytol, for treatment of iron deficiency anemia, 1
mg (non-ESRD use) K2 K

Feraheme is FDA approved for chronic kidney disease.

Other: Feraheme
✽ Q0139 Injection, ferumoxytol, for treatment of iron deficiency anemia, 1
mg (for ESRD on dialysis) K2 K

Other: Feraheme
Q0144 Azithromycin dihydrate, oral, capsules/powder, 1 gm E1

Other: Zithromax, Zmax

✽ Q0161 Chlorpromazine hydrochloride, 5 mg, oral, FDA approved
prescription antiemetic, for use as a complete therapeutic substitute
for an IV antiemetic at the time of chemotherapy treatment, not to
exceed a 48 hour dosage regimen N1 N

❂ Q0162 Ondansetron 1 mg, oral, FDA-approved prescription anti-emetic, for

use as a complete therapeutic substitute for an iv anti-emetic at the
time of chemotherapy treatment, not to exceed a 48 hour dosage
regimen N1 N

Other: Zofran
Medicare Statute 4557
Coding Clinic: 2012, Q1, P9
❂ Q0163 Diphenhydramine hydrochloride, 50 mg, oral, FDA approved
prescription anti-emetic, for use as a complete therapeutic substitute
for an IV antiemetic at time of chemotherapy treatment not to
exceed a 48 hour dosage regimen N1 N

Other: Alercap, Alertab, Allergy Relief Medicine, Allermax, Anti-

Hist, Antihistamine, Banophen, Complete Allergy Medication,
Complete Allergy medicine, Diphedryl, Diphenhist,
Diphenhydramine, Dormin Sleep Aid, Genahist, Geridryl, Good
Sense Antihistamine Allergy Relief, Good Sense Nighttime Sleep
Aid, Mediphedryl, Night Time Sleep Aid, Nytol Quickcaps, Nytol
Quickgels maximum strength, Quality Choice Sleep Aid, Quality
Choice Rest Simply, Rapidpaq Dicopanol, Rite Aid Allergy,
Serabrina La France, Siladryl Allergy, Silphen, Simply Sleep, Sleep
Tabs, Sleepinal, Sominex, Twilite, Valu-Dryl Allergy
Medicare Statute 4557
Coding Clinic: 2012, Q2, P10
❂ Q0164 Prochlorperazine maleate, 5 mg, oral, FDA approved prescription
 anti-emetic, for use as a complete therapeutic substitute for an IV
anti-emetic at the time of chemotherapy treatment, not to exceed a
48 hour dosage regimen N1 N

Other: Compazine
Medicare Statute 4557
Coding Clinic: 2012, Q2, P10
❂ Q0166 Granisetron hydrochloride, 1 mg, oral, FDA approved prescription
anti-emetic, for use as a complete therapeutic substitute for an IV
anti-emetic at the time of chemotherapy treatment, not to exceed a
24 hour dosage regimen N1 N

Other: Kytril
Medicare Statute 4557
Coding Clinic: 2012, Q2, P10
❂ Q0167 Dronabinol, 2.5 mg, oral, FDA approved prescription anti-emetic,
for use as a complete therapeutic substitute for an IV anti-emetic at
the time of chemotherapy treatment, not to exceed a 48 hour dosage
regimen N1 N

Other: Marinol
Medicare Statute 4557
Coding Clinic: 2012, Q2, P10
❂ Q0169 Promethazine hydrochloride, 12.5 mg, oral, FDA approved
prescription antiemetic, for use as a complete therapeutic substitute
for an IV antiemetic at the time of chemotherapy treatment, not to
exceed a 48 hour dosage regimen N1 N

Other: Anergan, Chlorpromazine, Hydroxyzine Pamoate,

Phenazine, Phenergan, Prorex, Prothazine, V-Gan
Medicare Statute 4557
Coding Clinic: 2012, Q2, P10
❂ Q0173 Trimethobenzamide hydrochloride, 250 mg, oral, FDA approved
prescription anti-emetic, for use as a complete therapeutic substitute
for an IV anti-emetic at the time of chemotherapy treatment, not to
exceed a 48 hour dosage regimen N1 N

Other: Arrestin, Ticon, Tigan, Tiject

Medicare Statute 4557
Coding Clinic: 2012, Q2, P10
❂ Q0174 Thiethylperazine maleate, 10 mg, oral, FDA approved prescription
anti-emetic, for use as a complete therapeutic substitute for an IV
anti-emetic at the time of chemotherapy treatment, not to exceed a
 48 hour dosage regimen E2

Other: Torecan
Medicare Statute 4557
Coding Clinic: 2012, Q2, P10
❂ Q0175 Perphenazine, 4 mg, oral, FDA approved prescription anti-emetic,
for use as a complete therapeutic substitute for an IV anti-emetic at
the time of chemotherapy treatment, not to exceed a 48 hour dosage
regimen N1 N

Medicare Statute 4557

Coding Clinic: 2012, Q2, P10
❂ Q0177 Hydroxyzine pamoate, 25 mg, oral, FDA approved prescription anti-
emetic, for use as a complete therapeutic substitute for an IV anti-
emetic at the time of chemotherapy treatment, not to exceed a 48
hour dosage regimen N1 N

Other: Vistaril
Medicare Statute 4557
Coding Clinic: 2012, Q2, P10
❂ Q0180 Dolasetron mesylate, 100 mg, oral, FDA approved prescription anti-
emetic, for use as a complete therapeutic substitute for an IV anti-
emetic at the time of chemotherapy treatment, not to exceed a 24
hour dosage regimen N1 N

Other: Anzemet
Medicare Statute 4557
Coding Clinic: 2012, Q2, P10
❂ Q0181 Unspecified oral dosage form, FDA approved prescription anti-
emetic, for use as a complete therapeutic substitute for a IV anti-
emetic at the time of chemotherapy treatment, not to exceed a 48
hour dosage regimen N1 N

Medicare Statute 4557

Coding Clinic: 2012, Q2, P10
▶ Q0221 Injection, tixagevimab and cilgavimab, for the pre-exposure
prophylaxis only, for certain adults and pediatric individuals (12
years of age and older weighing at least 40kg) with no known sars-
cov-2 exposure, who either have moderate to severely compromised
immune systems or for whom vaccination with any available covid-
19 vaccine is not recommended due to a history of severe adverse
reaction to a covid-19 vaccine(s) and/or covid-19 vaccine
component(s), 600 mg L1 L
 ▶ Q0222 Injection, bebtelovimab, 175 mg L1 L

❂ Q0240 Injection, casirivimab and imdevimab, 600 mg L1 L

❂ Q0243 Injection, Casirivimab and Imdevimab, 2400 mg K2 L

❂ Q0244 Injection, casirivimab and imdevimab, 1200 mg L1 L

❂ Q0245 Injection, bamlanivimab and etesevimab, 2100 mg L1 L

❂ Q0247 Injection, sotrovimab, 500 mg L1 L

❂ Q0249 Injection, tocilizumab, for hospitalized adults and pediatric patients

(2 years of age and older) with covid-19 who are receiving systemic
corticosteroids and require supplemental oxygen, noninvasive or
invasive mechanical ventilation, or extracorporeal L1 L

Ventricular Assist Devices

❂ Q0477 Power module patient cable for use with electric or
electric/pneumatic ventricular assist device, replacement only A

Figure 46 Ventricular assist device.

❂ Q0478 Power adapter for use with electric or electric/pneumatic ventricular

assist device, vehicle type A

CMS has determined the reasonable useful lifetime is one year. Add
modifier RA to claims to report when battery is replaced because it
was lost, stolen, or irreparably damaged.
❂ Q0479 Power module for use with electric or electric/pneumatic ventricular
assist device, replacemment only A

CMS has determined the reasonable useful lifetime is one year. Add
modifier RA in cases where the battery is being replaced because it
was lost, stolen, or irreparably damaged.
❂ Q0480 Driver for use with pneumatic ventricular assist device, replacement
only A
❂ Q0481 Microprocessor control unit for use with electric ventricular assist
device, replacement only A

❂ Q0482 Microprocessor control unit for use with electric/pneumatic

combination ventricular assist device, replacement only
A
❂ Q0483 Monitor/display module for use with electric ventricular assist
device, replacement only A

❂ Q0484 Monitor/display module for use with electric or electric/pneumatic

ventricular assist device, replacement only A

❂ Q0485 Monitor control cable for use with electric ventricular assist device,
replacement only A

❂ Q0486 Monitor control cable for use with electric/pneumatic ventricular

assist device, replacement only A

❂ Q0487 Leads (pneumatic/electrical) for use with any type

electric/pneumatic ventricular assist device, replacement only
A

❂ Q0488 Power pack base for use with electric ventricular assist device,
replacement only A

❂ Q0489 Power pack base for use with electric/pneumatic ventricular assist
device, replacement only A

❂ Q0490 Emergency power source for use with electric ventricular assist
device, replacement only A

❂ Q0491 Emergency power source for use with electric/pneumatic ventricular

assist device, replacement only A

❂ Q0492 Emergency power supply cable for use with electric ventricular
assist device, replacement only A

❂ Q0493 Emergency power supply cable for use with electric/pneumatic

ventricular assist device, replacement only A

❂ Q0494 Emergency hand pump for use with electric or electric/pneumatic

ventricular assist device, replacement only A

❂ Q0495 Battery/power pack charger for use with electric or

electric/pneumatic ventricular assist device, replacement only
A

❂ Q0496 Battery, other than lithium-ion, for use with electric or

electric/pneumatic ventricular assist device, replacement only
A
Reasonable useful lifetime is 6 months (CR3931).
❂ Q0497 Battery clips for use with electric or electric/pneumatic ventricular
assist device, replacement only A
 ❂ Q0498 Holster for use with electric or electric/pneumatic ventricular assist
device, replacement only A

❂ Q0499 Belt/vest/bag for use to carry external peripheral components of any

type ventricular assist device, replacement only A

❂ Q0500 Filters for use with electric or electric/pneumatic ventricular assist

device, replacement only A

❂ Q0501 Shower cover for use with electric or electric/pneumatic ventricular

assist device, replacement only A

❂ Q0502 Mobility cart for pneumatic ventricular assist device, replacement

only A

❂ Q0503 Battery for pneumatic ventricular assist device, replacement only,

each A

Reasonable useful lifetime is 6 months (CR3931).

❂ Q0504 Power adapter for pneumatic ventricular assist device, replacement
only, vehicle type A

❂ Q0506 Battery, lithium-ion, for use with electric or electric/pneumatic,

ventricular assist device, replacement only A

Reasonable useful lifetime is 12 months. Add -RA for replacement

if lost, stolen, or irreparable damage.
❂ Q0507 Miscellaneous supply or accessory for use with an external
ventricular assist device A

❂ Q0508 Miscellaneous supply or accessory for use with an implanted

ventricular assist device A

❂ Q0509 Miscellaneous supply or accessory for use with any implanted

ventricular assist device for which payment was not made under
Medicare Part A A

Pharmacy: Supply and Dispensing Fee

❂ Q0510 Pharmacy supply fee for initial immunosuppressive drug(s), first
month following transplant B

❂ Q0511 Pharmacy supply fee for oral anticancer, oral anti-emetic or

immunosuppressive drug(s); for the first prescription in a 30-day
period B

❂ Q0512 Pharmacy supply fee for oral anti-cancer, oral anti-emetic or

immunosuppressive drug(s); for a subsequent prescription in a 30-
day period B

❂ Q0513 Pharmacy dispensing fee for inhalation drug(s); per 30 days

B
 ❂ Q0514 Pharmacy dispensing fee for inhalation drug(s); per 90 days
B

Sermorelin Acetate
❂ Q0515 Injection, sermorelin acetate, 1 microgram E2

IOM: 100-02, 15, 50

New Technology: Intraocular Lens

❂ Q1004 New technology intraocular lens category 4 as defined in Federal
Register notice E1

❂ Q1005 New technology intraocular lens category 5 as defined in Federal

Register notice E1

Solutions and Drugs

❂ Q2004 Irrigation solution for treatment of bladder calculi, for example
renacidin, per 500 ml N1 N

IOM: 100-02, 15, 50

Medicare Statute 1861S2B
❂ Q2009 Injection, fosphenytoin, 50 mg phenytoin equivalent K2 K

IOM: 100-02, 15, 50

Medicare Statute 1861S2B
❂ Q2017 Injection, teniposide, 50 mg K2 K

IOM: 100-02, 15, 50

Medicare Statute 1861S2B
❂ Q2026 Injection, radiesse, 0.1 ml E2
Coding Clinic: 2010, Q3, P8
❂ Q2028 Injection, sculptra, 0.5 mg E2

❂ Q2034 Influenza virus vaccine, split virus, for intramuscular use (Agriflu)
Sipuleucel-t, minimum of 50 million autologous CD54+ cells
activated with PAP-GM-CSF, including leukapheresis and all other
preparatory procedures, per infusion L1 L

IOM: 100-02, 15, 50

❂ Q2035 Influenza virus vaccine, split virus, when administered to
individuals 3 years of age and older, for intramuscular use (Afluria)
L1 L

Preventive service; no deductible

 IOM: 100-02, 15, 50
Coding Clinic: 2011, Q1, P7; 2010, Q4, P8-9
❂ Q2036 Influenza virus vaccine, split virus, when administered to
individuals 3 years of age and older, for intramuscular use (Flulaval)
L1 L

Preventive service; no deductible

IOM: 100-02, 15, 50
Coding Clinic: 2011, Q1, P7; 2010, Q4, P8-9
❂ Q2037 Influenza virus vaccine, split virus, when administered to
individuals 3 years of age and older, for intramuscular use (Fluvirin)
L1 L

Preventive service; no deductible

IOM: 100-02, 15, 50
Coding Clinic: 2011, Q1, P7; 2010, Q4, P8-9
❂ Q2038 Influenza virus vaccine, split virus, when administered to
individuals 3 years of age or older, for intramuscular use (Fluzone)
L1 L

Preventive service; no deductible

IOM: 100-02, 15, 50
Coding Clinic: 2011, Q1, P7; 2010, Q4, P8-9
❂ Q2039 Influenza virus vaccine, not otherwise specified L1 L

Preventive service; no deductible

IOM: 100-02, 15, 50
Coding Clinic: 2011, Q1, P7; 2010, Q4, P8-9
❂ Q2041 Axicabtagene ciloleucel, up to 200 million autologous anti-CD 19
CAR-positive viable T cells, including leukapheresis and dose
preparation procedures, per therapeutic dose G

❂ Q2042 Tisagenlecleucel, up to 600 million CAR-positive viable T cells,

including leukapheresis and dose preparation procedures, per
therapeutic dose G

❂ Q2043 Sipuleucel-T, minimum of 50 million autologous CD54+ cells

activated with PAP-GM-CSF, including leukapheresis and all other
preparatory procedures, per infusion K2 K

Other: Provenge
Coding Clinic: 2012, Q2, P7; Q1, P7, 9; 2011, Q3, P9
✽ Q2049 Injection, doxorubicin hydrochloride, liposomal, imported lipodox,
10 mg K2 K
Coding Clinic: 2012, Q3, P10
 ❂ Q2050 Injection, doxorubicin hydrochloride, liposomal, not otherwise
specified, 10 mg K2 K

Other: Doxil
IOM: 100-02, 15, 50
❂ Q2052 Services, supplies and accessories used in the home under the
Medicare intravenous immune globulin (IVIG) demonstration
E1
Coding Clinic: 2014, Q2, P6
❂ Q2053 Brexucabtagene autoleucel, up to 200 million autologous anti-cd19
car positive viable t cells, including leukapheresis and dose
preparation procedures, per therapeutic dose G

❂ Q2054 Lisocabtagene maraleucel, up to 110 million autologous anti-cd19

carpositive viable t cells, including leukapheresis and dose
preparation procedures, per therapeutic dose G

❂ Q2055 Idecabtagene vicleucel, up to 460 million autologous b-cell

maturation antigen (bcma) directed car-positive t cells, including
leukapheresis and dose preparation procedures, per therapeutic dose
G
▶ Q2056 Ciltacabtagene autoleucel, up to 100 million autologous B-cell
maturation antigen (bcma) directed car-positive T cells, including
leukapheresis and dose preparation procedures, per therapeutic dose
G

Brachytherapy Radioelements
❂ Q3001 Radioelements for brachytherapy, any type, each B

IOM: 100-04, 12, 70; 100-04, 13, 20

Telehealth
✽ Q3014 Telehealth originating site facility fee A

Effective January of each year, the fee for telehealth services is

increased by the Medicare Economic Index (MEI). The telehealth
originating facility site fee (HCPCS code Q3014) for 2011 was 80
percent of the lesser of the actual charge or $24.10.

Drugs
❂ Q3027 Injection, interferon beta-1a, 1 mcg for intramuscular use
K2 K
Other: Avonex
IOM: 100-02, 15, 50
 Q3028 Injection, interferon beta-1a, 1 mcg for subcutaneous use
E1

Skin Test
❂ Q3031 Collagen skin test N1 N

IOM: 100-03, 4, 280.1

Supplies: Cast

Q4001-Q4051: Payment on a reasonable charge basis is required for splints,

casts by regulations contained in 42 CFR 405.501.
✽ Q4001 Casting supplies, body cast adult, with or without head, plaster
B

✽ Q4002 Cast supplies, body cast adult, with or without head, fiberglass
B

✽ Q4003 Cast supplies, shoulder cast, adult (11 years +), plaster
B
✽ Q4004 Cast supplies, shoulder cast, adult (11 years +), fiberglass
B

✽ Q4005 Cast supplies, long arm cast, adult (11 years +), plaster B

✽ Q4006 Cast supplies, long arm cast, adult (11 years +), fiberglass B

✽ Q4007 Cast supplies, long arm cast, pediatric (0-10 years), plaster
B
✽ Q4008 Cast supplies, long arm cast, pediatric (0-10 years), fiberglass
B
✽ Q4009 Cast supplies, short arm cast, adult (11 years +), plaster B

✽ Q4010 Cast supplies, short arm cast, adult (11 years +), fiberglass B

✽ Q4011 Cast supplies, short arm cast, pediatric (0-10 years), plaster
B
✽ Q4012 Cast supplies, short arm cast, pediatric (0-10 years), fiberglass
B
✽ Q4013 Cast supplies, gauntlet cast (includes lower forearm and hand), adult
(11 years +), plaster B

✽ Q4014 Cast supplies, gauntlet cast (includes lower forearm and hand), adult
(11 years +), fiberglass B

✽ Q4015 Cast supplies, gauntlet cast (includes lower forearm and hand),
pediatric (0-10 years), plaster B

✽ Q4016 Cast supplies, gauntlet cast (includes lower forearm and hand),
pediatric (0-10 years), fiberglass B
✽ Q4017 Cast supplies, long arm splint, adult (11 years +), plaster B

✽ Q4018 Cast supplies, long arm splint, adult (11 years +), fiberglass
B
✽ Q4019 Cast supplies, long arm splint, pediatric (0-10 years), plaster
B
✽ Q4020 Cast supplies, long arm splint, pediatric (0-10 years), fiberglass
B
✽ Q4021 Cast supplies, short arm splint, adult (11 years +), plaster B

✽ Q4022 Cast supplies, short arm splint, adult (11 years +), fiberglass
B
✽ Q4023 Cast supplies, short arm splint, pediatric (0-10 years), plaster
B
✽ Q4024 Cast supplies, short arm splint, pediatric (0-10 years), fiberglass
B
✽ Q4025 Cast supplies, hip spica (one or both legs), adult (11 years +), plaster
B

✽ Q4026 Cast supplies, hip spica (one or both legs), adult (11 years +),
fiberglass B

✽ Q4027 Cast supplies, hip spica (one or both legs), pediatric (0-10 years),
plaster B

✽ Q4028 Cast supplies, hip spica (one or both legs), pediatric (0-10 years),
fiberglass B

✽ Q4029 Cast supplies, long leg cast, adult (11 years +), plaster B

✽ Q4030 Cast supplies, long leg cast, adult (11 years +), fiberglass B

✽ Q4031 Cast supplies, long leg cast, pediatric (0-10 years), plaster B

✽ Q4032 Cast supplies, long leg cast, pediatric (0-10 years), fiberglass
B
✽ Q4033 Cast supplies, long leg cylinder cast, adult (11 years +), plaster
B
✽ Q4034 Cast supplies, long leg cylinder cast, adult (11 years +), fiberglass
B

✽ Q4035 Cast supplies, long leg cylinder cast, pediatric (0-10 years), plaster
B

✽ Q4036 Cast supplies, long leg cylinder cast, pediatric (0-10 years),
fiberglass B

✽ Q4037 Cast supplies, short leg cast, adult (11 years +), plaster B

✽ Q4038 Cast supplies, short leg cast, adult (11 years +), fiberglass B

✽ Q4039 Cast supplies, short leg cast, pediatric (0-10 years), plaster B
 ✽ Q4040 Cast supplies, short leg cast, pediatric (0-10 years), fiberglass
B
✽ Q4041 Cast supplies, long leg splint, adult (11 years +), plaster B

✽ Q4042 Cast supplies, long leg splint, adult (11 years +), fiberglass
B
✽ Q4043 Cast supplies, long leg splint, pediatric (0-10 years), plaster
B
✽ Q4044 Cast supplies, long leg splint, pediatric (0-10 years), fiberglass
B
✽ Q4045 Cast supplies, short leg splint, adult (11 years +), plaster B

✽ Q4046 Cast supplies, short leg splint, adult (11 years +), fiberglass
B
✽ Q4047 Cast supplies, short leg splint, pediatric (0-10 years), plaster
B
✽ Q4048 Cast supplies, short leg splint, pediatric (0-10 years), fiberglass
B
✽ Q4049 Finger splint, static B

✽ Q4050 Cast supplies, for unlisted types and materials of casts B

✽ Q4051 Splint supplies, miscellaneous (includes thermoplastics, strapping,

fasteners, padding and other supplies) B

Figure 47 Finger splint.

Drugs
✽ Q4074 Iloprost, inhalation solution, FDA-approved final product, non-
compounded, administered through DME, unit dose form, up to 20
micrograms Y

Other: Ventavis
❂ Q4081 Injection, epoetin alfa, 100 units (for ESRD on dialysis) N
 Other: Epogen, Procrit
✽ Q4082 Drug or biological, not otherwise classified, Part B drug competitive
acquisition program (CAP) B
Skin Substitutes
✽ Q4100 Skin substitute, not otherwise specified N1 N
Coding Clinic: 2018, Q2, P3; 2012, Q2, P7
✽ Q4101 Apligraf, per square centimeter N1 N
Coding Clinic: 2012, Q2, P7; 2011, Q1, P9
✽ Q4102 Oasis Wound Matrix, per square centimeter N1 N
Coding Clinic: 2012, Q3, P8; Q2, P7; 2011, Q1, P9
✽ Q4103 Oasis Burn Matrix, per square centimeter N1 N
Coding Clinic: 2012, Q2, P7; 2011, Q1, P9
✽ Q4104 Integra Bilayer Matrix Wound Dressing (BMWD), per square
centimeter N1 N
Coding Clinic: 2012, Q2, P7; 2011, Q1, P9; 2010, Q2, P8
✽ Q4105 Integra Dermal Regeneration Template (DRT) or integra omnigraft
dermal regeneration matrix, per square centimeter N1 N
Coding Clinic: 2012, Q2, P7; 2011, Q1, P9; 2010, Q2, P8
✽ Q4106 Dermagraft, per square centimeter N1 N
Coding Clinic: 2012, Q2, P7; 2011, Q1, P9
✽ Q4107 Graftjacket, per square centimeter N1 N
Coding Clinic: 2021, Q1, P9; 2012, Q2, P7; 2011, Q1, P9
✽ Q4108 Integra Matrix, per square centimeter N1 N
Coding Clinic: 2012, Q2, P7; 2011, Q1, P9; 2010, Q2, P8
✽ Q4110 Primatrix, per square centimeter N1 N
Coding Clinic: 2012, Q2, P7; 2011, Q1, P9
✽ Q4111 GammaGraft, per square centimeter N1 N
Coding Clinic: 2012, Q2, P7; 2011, Q1, P9
✽ Q4112 Cymetra, injectable, 1 cc N1 N
Coding Clinic: 2012, Q2, P7; 2011, Q1, P9
✽ Q4113 GraftJacket Xpress, injectable, 1 cc N1 N
Coding Clinic: 2012, Q2, P7; 2011, Q1, P9
✽ Q4114 Integra Flowable Wound Matrix, injectable, 1 cc N1 N
Coding Clinic: 2012, Q2, P7; 2010, Q2, P8
✽ Q4115 Alloskin, per square centimeter N1 N
Coding Clinic: 2012, Q2, P7; 2011, Q1, P9
✽ Q4116 Alloderm, per square centimeter N1 N
Coding Clinic: 2012, Q2, P7; 2011, Q1, P9
✽ Q4117 Hyalomatrix, per square centimeter N1 N

IOM: 100-02, 15, 50

✽ Q4118 Matristem micromatrix, 1 mg N1 N
Coding Clinic: 2013, Q4, P2; 2012, Q2, P7; 2011, Q1, P6
✽ Q4121 Theraskin, per square centimeter N1 N
Coding Clinic: 2012, Q2, P7; 2011, Q1, P6
✽ Q4122 Dermacell, Dermacell AWM or Dermacell AWM Porous, per square
centimeter N1 N
Coding Clinic: 2012, Q2, P7; Q1, P8
✽ Q4123 AlloSkin RT, per square centimeter N1 N

✽ Q4124 Oasis Ultra Tri-layer Wound Matrix, per square centimeter

Coding Clinic: 2012, Q2, P7; Q1, P9 N1 N

✽ Q4125 Arthroflex, per square centimeter N1 N

✽ Q4126 Memoderm, dermaspan, tranzgraft or integuply, per square

centimeter N1 N

✽ Q4127 Talymed, per square centimeter N1 N

✽ Q4128 FlexHD, Allopatch HD, per square centimeter N1 N

✽ Q4130 Strattice TM, per square centimeter N1 N

Coding Clinic: 2012, Q2, P7
✽ Q4132 Grafix core and GrafixPL core, per square centimeter
N1 N
✽ Q4133 Grafix prime, GrafixPL prime, stravix and stravixpl, per square
centimeter N1 N

✽ Q4134 Hmatrix, per square centimeter N1 N

✽ Q4135 Mediskin, per square centimeter N1 N

✽ Q4136 Ez-derm, per square centimeter N1 N

✽ Q4137 Amnioexcel, amnioexcel plus or biodexcel, per square centimeter

N1 N

✽ Q4138 Biodfence dryflex, per square centimeter N1 N

✽ Q4139 Amniomatrix or biodmatrix, injectable, 1 cc N1 N

✽ Q4140 Biodfence, per square centimeter N1 N

✽ Q4141 Alloskin ac, per square centimeter N1 N

✽ Q4142 XCM biologic tissue matrix, per square centimeter N1 N

✽ Q4143 Repriza, per square centimeter N1 N

✽ Q4145 Epifix, injectable, 1 mg N1 N

✽ Q4146 Tensix, per square centimeter N1 N

✽ Q4147 Architect, architect PX, or architect FX, extracellular matrix, per

 square centimeter N1 N

✽ Q4148 Neox cord 1K, Neox cord RT, or Clarix cord 1K, per square
centimeter N1 N

✽ Q4149 Excellagen, 0.1 cc N1 N

✽ Q4150 AlloWrap DS or dry, per square centimeter N1 N

✽ Q4151 Amnioband or guardian, per square centimeter N1 N

✽ Q4152 DermaPure, per square centimeter N1 N

✽ Q4153 Dermavest and Plurivest, per square centimeter N1 N

✽ Q4154 Biovance, per square centimeter N1 N

✽ Q4155 Neoxflo or clarixflo, 1 mg N1 N

✽ Q4156 Neox 100 or Clarix 100, per square centimeter N1 N

✽ Q4157 Revitalon, per square centimeter N1 N

✽ Q4158 Kerecis Omega3, per square centimeter N1 N

✽ Q4159 Affinity, per square centimeter N1 N

✽ Q4160 Nushield, per square centimeter N1 N

✽ Q4161 Bio-ConneKt Wound Matrix, per square centimeter N1 N

✽ Q4162 Woundex flow, BioSkin flow 0.5 cc N1 N

✽ Q4163 Woundex, BioSkin per square centimeter N1 N

✽ Q4164 Helicoll, per square centimeter N1 N

✽ Q4165 Keramatrix or kerasorb, per square centimeter N1 N

✽ Q4166 Cytal, per square centimeter N1 N

Coding Clinic: 2017, Q1, P10
✽ Q4167 TruSkin, per square centimeter N1 N
Coding Clinic: 2017, Q1, P10
✽ Q4168 AmnioBand, 1 mg N1 N
Coding Clinic: 2017, Q1, P10
✽ Q4169 Artacent wound, per square centimeter N1 N
Coding Clinic: 2017, Q1, P10
✽ Q4170 Cygnus, per square centimeter N1 N
Coding Clinic: 2017, Q1, P10
✽ Q4171 Interfyl, 1 mg N1 N
Coding Clinic: 2017, Q1, P10
✽ Q4173 PalinGen or PalinGen XPlus, per square centimeter N1 N
Coding Clinic: 2017, Q1, P10
✽ Q4174 PalinGen or ProMatrX, 0.36 mg per 0.25 cc N1 N
 Coding Clinic: 2017, Q1, P10
✽ Q4175 Miroderm, per square centimeter N1 N
Coding Clinic: 2017, Q1, P10
✽ Q4176 Neopatch or therion, per square centimeter N1 N

✽ Q4177 Floweramnioflo, 0.1 cc N1 N

✽ Q4178 Floweramniopatch, per square centimeter N1 N

✽ Q4179 Flowerderm, per square centimeter N1 N

✽ Q4180 Revita, per square centimeter N1 N

✽ Q4181 Amnio wound, per square centimeter N1 N

✽ Q4182 Transcyte, per square centimeter N1 N

✽ Q4183 Surgigraft, per square centimeter N

✽ Q4184 Cellesta or cellesta duo, per square centimeter N

✽ Q4185 Cellesta flowable amnion (25 mg per cc); per 0.5 cc N

✽ Q4186 Epifix, per square centimeter N

✽ Q4187 Epicord, per square centimeter N

✽ Q4188 Amnioarmor, per square centimeter N

✽ Q4189 Artacent ac, 1 mg N

✽ Q4190 Artacent ac, per square centimeter N

✽ Q4191 Restorigin, per square centimeter N

✽ Q4192 Restorigin, 1 cc N

✽ Q4193 Coll-e-derm, per square centimeter N

✽ Q4194 Novachor, per square centimeter N

✽ Q4195 Puraply, per square centimeter G

✽ Q4196 Puraply am, per square centimeter G

✽ Q4197 Puraply xt, per square centimeter N

✽ Q4198 Genesis amniotic membrane, per square centimeter N

✽ Q4199 Cygnus matrix, per square centimeter N

✽ Q4200 Skin te, per square centimeter N

✽ Q4201 Matrion, per square centimeter N

✽ Q4202 Keroxx (2.5g/cc), 1cc N

✽ Q4203 Derma-gide, per square centimeter N

✽ Q4204 Xwrap, per square centimeter N

✽ Q4205 Membrane graft or membrane wrap, per square centimeter
✽ Q4206 Fluid flow or fluid Gf, 1 cc N

✽ Q4208 Novafix, per square cenitmeter N

✽ Q4209 Surgraft, per square centimeter N

✽ Q4210 Axolotl graft or axolotl dualgraft, per square centimeter N

✽ Q4211 Amnion bio or axobiomembrane, per square centimeter N

✽ Q4212 Allogen, per cc N

✽ Q4213 Ascent, 0.5 mg N

✽ Q4214 Cellesta cord, per square centimeter N

✽ Q4215 Axolotl ambient or axolotl cryo, 0.1 mg N

✽ Q4216 Artacent cord, per square centimeter N

✽ Q4217 Woundfix, BioWound, Woundfix Plus, BioWound Plus, Woundfix

Xplus or BioWound Xplus, per square centimeter N

✽ Q4218 Surgicord, per square centimeter N

✽ Q4219 Surgigraft-dual, per square centimeter N

✽ Q4220 BellaCell HD or Surederm, per square centimeter N

✽ Q4221 Amniowrap2, per square centimeter N

✽ Q4222 Progenamatrix, per square centimeter N

✽ Q4226 MyOwn skin, includes harvesting and preparation procedures, per

square centimeter N

✽ Q4227 Amniocore, per square centimeter N1 N

✽ Q4229 Cogenex amniotic membrane, per square centimeter N1 N

✽ Q4230 Cogenex flowable amnion, per 0.5 cc N1 N

✽ Q4231 Corplex P, per cc N1 N

✽ Q4232 Corplex, per square centimeter N1 N

✽ Q4233 Surfactor or Nudyn, per 0.5 cc N1 N

✽ Q4234 Xcellerate, per square centimeter N1 N

✽ Q4235 Amniorepair or Altiply, per square centimeter N1 N

✽ Q4237 Cryo-cord, per square centimeter N1 N

✽ Q4238 Derm-maxx, per square centimeter N1 N

✽ Q4239 Amnio-maxx or amnio-maxx lite, per square centimeter N1 N

✽ Q4240 Corecyte, for topical use only, per 0.5 cc N1 N

 ✽ Q4241 Polycyte, for topical use only, per 0.5 cc N1 N

✽ Q4242 Amniocyte plus, per 0.5 cc N1 N

✽ Q4244 Procenta, per 200 mg N1 N

✽ Q4245 Amniotext, per cc N1 N

✽ Q4246 Coretext or Protext, per cc N1 N

✽ Q4248 Dermacyte amniotic membrane allograft, per square centimeter

N1 N
✽ Q4249 Amniply, for topical use only, per square centimeter N

✽ Q4950 Amnioamp-MP, per square centimeter N

✽ Q4251 Vim, per square centimeter N

✽ Q4252 Vendaje, per square centimeter N

✽ Q4253 Zenith amniotic membrane, per square centimeter N

✽ Q4254 Novafix DL, per square centimeter N

✽ Q4255 Reguard, for topical use only, per square centimeter N

▶ ❂ Q4259 Celera dual layer or celera dual membrane, per square centimeter N

▶ ❂ Q4260 Signature apatch, per square centimeter N

▶ ❂ Q4261 Tag, per square centimeter N

▶ ❂ Q4262 Dual layer impax membrane, per square centimeter N

▶ ❂ Q4263 Surgraft tl, per square centimeter N

▶ ❂ Q4264 Cocoon membrane, per square centimeter N

▶ ❂ Q5126 Injection, bevacizumab-maly, biosimilar, (alymsys), 10 mg G

Hospice Care
❂ Q5001 Hospice or home health care provided in patient’s home/residence
B
❂ Q5002 Hospice or home health care provided in assisted living facility B

❂ Q5003 Hospice care provided in nursing long term care facility (LTC) or
non-skilled nursing facility (NF) B

❂ Q5004 Hospice care provided in skilled nursing facility (SNF) B

❂ Q5005 Hospice care provided in inpatient hospital B

❂ Q5006 Hospice care provided in inpatient hospice facility B

Hospice care provided in an inpatient hospice facility. These are

residential facilities, which are places for patients to live while
receiving routine home care or continuous home care. These hospice
residential facilities are not certified by Medicare or Medicaid for
 provision of General Inpatient (GIP) or respite care, and regulations
at 42 CFR 418.202(e) do not allow provision of GIP or respite care
at hospice residential facilities.
❂ Q5007 Hospice care provided in long term care facility B

❂ Q5008 Hospice care provided in inpatient psychiatric facility B

❂ Q5009 Hospice or home health care provided in place not otherwise

specified (NOS) B

❂ Q5010 Hospice home care provided in a hospice facility B

Biosimilar Drugs
❂ Q5101 Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram
K2 G
Other: Zarxio
❂ Q5103 Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg G

Other: Remicade, Inflectra, Renflexis

❂ Q5104 Injection, infliximab-abda, biosimilar, (renflexis), 10 mgn
K2 G
Other: Remicade
❂ Q5105 Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for ESRD on
dialysis), 100 units K2 G

Other: Retacrit
❂ Q5106 Injection, epoetin alfa-epbx, biosimilar (retacrit) (for non-ESRD
use), 1000 units G

Other: Retacrit
❂ Q5107 Injection, bevacizumab-awwb, biosimilar (mvasi), 10 mg E2

Other: Avastin
❂ Q5108 Injection, pegfilgrastim-jmdb, biosimilar (fulphila), 0.5 mg K

Other: Neulasta
❂ Q5109 Injection, infliximab-qbtx, biosimilar (ixifi), 10 mg E2

Other: Remicade, Inflectra, Renflexis

❂ Q5110 Injection, filgrastim-aafi, biosimilar (nivestym), 1 microgram
K
Other: Nivestym
✽ Q5112 Injection, trastuzumab-dttb, biosimilar (ontruzant), 10 mg E2

✽ Q5113 Injection, trastuzumab-pkrb, biosimilar (herzuma), 10 mg E2

✽ Q5114 Injection, trastuzumab-dkst, biosimilar (ogivri), 10 mg E2

 ❂ Q5115 Injection, rituximab-abbs, biosimilar (truxima), 10 mg E2

✽ Q5116 Injection, trastuzumab-qyyp, biosimilar (trazimera), 10 mg E2

✽ Q5117 Injection, trastuzumab-anns, biosimilar (kanjinti), 10 mg K2 G

✽ Q5118 Injection, bevacizumab-bvzr, biosimilar (zirabev), 10 mg E2

✽Q5119 Injection, rituximab-pvvr, biosimilar (ruxience), 10 mg G

✽Q5120 Injection, pegfilgrastim-bmez, biosimilar (ziextenzo), 0.5 mg K2 G

✽ Q5121 Injection, infliximab-axxq, biosimilar (avsola), 10 mg K2 G

✽ Q5122 Injection, pegfilgrastim-apgf, biosimilar (nyvepria), 0.5 mg K5 E1

✽ Q5123 Injection, rituximab-arrx, biosimilar, (riabni), 10 mg K2 G

▶ Q5125 Injection, filgrastim-ayow, biosimilar, (releuko), 1 microgram

K2 G

Veteran Services Chaplain

✽ Q9001 Assessment by chaplain services E1

✽ Q9002 Counseling, individual, by chaplain services E1

✽ Q9003 Counseling, group, by chaplain services E1

✽ Q9004 Department of veterans affairs whole health partner services E1

Contrast Agents
✽ Q9950 Injection, sulfur hexafluoride lipid microspheres, per ml
N1 N
Other: Lumason
❂ Q9951 Low osmolar contrast material, 400 or greater mg/ml iodine
concentration, per ml N1 N

IOM: 100-04, 12, 70; 100-04, 13, 20; 100-04, 13, 90

Coding Clinic: 2012, Q3, P8
❂ Q9953 Injection, iron-based magnetic resonance contrast agent, per ml
N1 N

IOM: 100-04, 12, 70; 100-04, 13, 20; 100-04, 13, 90

Coding Clinic: 2012, Q3, P8
❂ Q9954 Oral magnetic resonance contrast agent, per 100 ml N1 N

IOM: 100-04, 12, 70; 100-04, 13, 20; 100-04, 13, 90

Coding Clinic: 2012, Q3, P8
✽ Q9955 Injection, perflexane lipid microspheres, per ml N1 N
Coding Clinic: 2012, Q3, P8
✽ Q9956 Injection, octafluoropropane microspheres, per ml N1 N
 Other: Optison
Coding Clinic: 2012, Q3, P8
✽ Q9957 Injection, perflutren lipid microspheres, per ml N1 N

Other: Definity
Coding Clinic: 2012, Q3, P8
❂ Q9958 High osmolar contrast material, up to 149 mg/ml iodine
concentration, per ml N1 N

Other: Conray 30, Cysto-Conray II, Cystografin

IOM: 100-04, 12, 70; 100-04, 13, 20; 100-04, 13, 90
Coding Clinic: 2012, Q3, P8; 2007, Q1, P6
❂ Q9959 High osmolar contrast material, 150-199 mg/ml iodine
concentration, per ml N1 N

IOM: 100-04, 12, 70; 100-04, 13, 20; 100-04, 13, 90

Coding Clinic: 2012, Q3, P8; 2007, Q1, P6
❂ Q9960 High osmolar contrast material, 200-249 mg/mliodine
concentration, per ml N1 N

Other: Conray 43
IOM: 100-04, 12, 70; 100-04, 13, 20; 100-04, 13, 90
Coding Clinic: 2012, Q3, P8; 2007, Q1, P6
❂ Q9961 High osmolar contrast material, 250-299 mg/mliodine
concentration, per ml N1 N

Other: Conray, Cholografin Meglumine

IOM: 100-04, 12, 70; 100-04, 13, 20; 100-04, 13, 90
Coding Clinic: 2012, Q3, P8; 2007, Q1, P6
❂ Q9962 High osmolar contrast material, 300-349 mg/ml iodine
concentration, per ml N1 N

IOM: 100-04, 12, 70; 100-04, 13, 20; 100-04, 13, 90

Coding Clinic: 2012, Q3, P8; 2007, Q1, P6
❂ Q9963 High osmolar contrast material, 350-399 mg/ml iodine
concentration, per ml N1 N

Other: Gastrografin, MD-76R, MD Gastroview, Sinografin

IOM: 100-04, 12, 70; 100-04, 13, 20; 100-04, 13, 90
Coding Clinic: 2012, Q3, P8; 2007, Q1, P6
❂ Q9964 High osmolar contrast material, 400 or greater mg/ml iodine
concentration, per ml N1 N

IOM: 100-04, 12, 70; 100-04, 13, 20; 100-04, 13, 90

Coding Clinic: 2012, Q3, P8; 2007, Q1, P6
 ❂ Q9965 Low osmolar contrast material, 100-199 mg/ml iodine
concentration, per ml N1 N

Other: Omnipaque
IOM: 100-04, 12, 70; 100-04, 13, 20; 100-04, 13, 90
Coding Clinic: 2012, Q3, P8
❂ Q9966 Low osmolar contrast material, 200-299 mg/ml iodine
concentration, per ml N1 N

Other: Isovue, Omnipaque, Optiray, Ultravist 240, Visipaque

IOM: 100-04, 12, 70; 100-04, 13, 20; 100-04, 13, 90
Coding Clinic: 2012, Q3, P8
❂ Q9967 Low osmolar contrast material, 300-399 mg/ml iodine
concentration, per ml N1 N

Other: Hexabrix 320, Isovue, Omnipaque, Optiray, Oxilan,

Ultravist, Vispaque
IOM: 100-04, 12, 70; 100-04, 13, 20; 100-04, 13, 90
Coding Clinic: 2012, Q3, P8
✽ Q9968 Injection, non-radioactive, noncontrast, visualization adjunct (e.g.,
Methylene Blue, Isosulfan Blue), 1 mg K2 K

❂ Q9969 Tc-99m from non-highly enriched uranium source, full cost

recovery add-on, per study dose K

Radiopharmaceuticals
❂ Q9982 Flutemetamol F18, diagnostic, per study dose, up to 5 millicuries
K2 G

Other: Vizamyl
❂ Q9983 Florbetaben F18, diagnostic, per study dose, up to 8.1 millicuries
K2 G

Other: Neuraceq
✽ Q9991 Injection, buprenorphine extendedrelease (sublocade), less than or
equal to 100 mg G

Other: Subutex, Buprenex, Belbuca, Probuphine, Butrans

✽ Q9992 Injection, buprenorphine extendedrelease (sublocade), greater than
100 mg G

Other: Subutex, Buprenex, Belbuca, Probuphine, Butrans

DIAGNOSTIC RADIOLOGY SERVICES (R0000-R9999)

Transportation/Setup of Portable Equipment
❂ R0070 Transportation of portable x-ray equipment and personnel to home
or nursing home, per trip to facility or location, one patient seen
B

CMS Transmittal B03-049; specific instructions to contractors on

pricing
IOM: 100-04, 13, 90; 100-04, 13, 90.3
❂ R0075 Transportation of portable x-ray equipment and personnel to home
or nursing home, per trip to facility or location, more than one
patient seen B

This code would not apply to the x-ray equipment if stored at the
location where the x-ray was performed (e.g., a nursing home).
IOM: 100-04, 13, 90; 100-04, 13, 90.3
❂ R0076 Transportation of portable ECG to facility or location, per patient
B

EKG procedure code 93000 or 93005 must be submitted on same

claim as transportation code. Bundled status on physician fee
schedule
IOM: 100-01, 5, 90.2; 100-02, 15, 80; 100-03, 1, 20.15; 100-04, 13,
90; 100-04, 16, 10; 100-04, 16, 110.4

TEMPORARY NATIONAL CODES ESTABLISHED BY

PRIVATE PAYERS (S0000-S9999)
NOTE: Medicare and other federal payers do not recognize “S” codes; however, S
codes may be useful for claims to some private insurers.

Non-Medicare Drugs
S0012 Butorphanol tartrate, nasal spray, 25 mg
S0013 Esketamine, nasal spray, 1 mg
S0014 Tacrine hydrochloride, 10 mg
S0017 Injection, aminocaproic acid, 5 grams
S0020 Injection, bupivacaine hydrochloride, 30 ml
S0021 Injection, cefoperazone sodium, 1 gram

Injection, cimetidine hydrochloride, 300 mg

S0023
S0028 Injection, famotidine, 20 mg
S0030 Injection, metronidazole, 500 mg
S0032 Injection, nafcillin sodium, 2 grams
S0034 Injection, ofloxacin, 400 mg
S0039 Injection, sulfamethoxazole and trimethoprim, 10 ml
S0040 Injection, ticarcillin disodium and clavulanate potassium, 3.1 grams
S0073 Injection, aztreonam, 500 mg
S0074 Injection, cefotetan disodium, 500 mg
S0077 Injection, clindamycin phosphate, 300 mg
S0078 Injection, fosphenytoin sodium, 750 mg
S0080 Injection, pentamidine isethionate, 300 mg
S0081 Injection, piperacillin sodium, 500 mg
S0088 Imatinib, 100 mg
S0090 Sildenafil citrate, 25 mg
S0091 Granisetron hydrochloride, 1 mg (for circumstances falling under
the Medicare Statute, use Q0166)
S0092 Injection, hydromorphone hydrochloride, 250 mg (loading dose for
infusion pump)
S0093 Injection, morphine sulfate, 500 mg (loading dose for infusion
pump)
S0104 Zidovudine, oral, 100 mg
S0106 Bupropion HCl sustained release tablet, 150 mg, per bottle of 60
tablets
S0108 Mercaptopurine, oral, 50 mg
S0109 Methadone, oral, 5 mg
S0117 Tretinoin, topical, 5 grams
S0119 Ondansetron, oral, 4 mg (for circumstances falling under the
Medicare statute, use HCPCS Q code)
S0122 Injection, menotropins, 75 IU
S0126 Injection, follitropin alfa, 75 IU
S0128 Injection, follitropin beta, 75 IU
S0132 Injection, ganirelix acetate, 250 mcg
S0136 Clozapine, 25 mg
S0137 Didanosine (DDI), 25 mg
S0138 Finasteride, 5 mg
S0139 Minoxidil, 10 mg
S0140 Saquinavir, 200 mg
S0142 Colistimethate sodium, inhalation solution administered through
DME, concentrated form, per mg
S0145 Injection, pegylated interferon alfa-2a, 180 mcg per ml
S0148 Injection, pegylated interferon ALFA-2b, 10 mcg
S0155 Sterile dilutant for epoprostenol, 50 ml
S0156 Exemestane, 25 mg
S0157 Becaplermin gel 0.01%, 0.5 gm
S0160 Dextroamphetamine sulfate, 5 mg
S0164 Injection, pantoprazole sodium, 40 mg
S0166 Injection, olanzapine, 2.5 mg
S0169 Calcitrol, 0.25 microgram
S0170 Anastrozole, oral, 1 mg
S0171 Injection, bumetanide, 0.5 mg
S0172 Chlorambucil, oral, 2 mg
S0174 Dolasetron mesylate, oral 50 mg (for circumstances falling under
the Medicare Statute, use Q0180)
S0175 Flutamide, oral, 125 mg
S0176 Hydroxyurea, oral, 500 mg
S0177 Levamisole hydrochloride, oral, 50 mg
S0178 Lomustine, oral, 10 mg
S0179 Megestrol acetate, oral, 20 mg
S0182 Procarbazine hydrochloride, oral, 50 mg
S0183 Prochlorperazine maleate, oral, 5 mg (for circumstances falling
under the Medicare Statute, use Q0164)
S0187 Tamoxifen citrate, oral, 10 mg
S0189 Testosterone pellet, 75 mg
S0190 Mifepristone, oral, 200 mg
S0191 Misoprostol, oral 200 mcg
 S0194 Dialysis/stress vitamin supplement, oral, 100 capsules
S0197 Prenatal vitamins, 30-day supply ♀

Provider Services
S0199 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 ♀
S0201 Partial hospitalization services, less than 24 hours, per diem
S0207 Paramedic intercept, non-hospital-based ALS service (non-
voluntary), non-transport
S0208 Paramedic intercept, hospital-based ALS service (non-voluntary),
nontransport
S0209 Wheelchair van, mileage, per mile
S0215 Non-emergency transportation; mileage per mile
S0220 Medical conference by a physician with interdisciplinary team of
health professionals or representatives of community agencies to
coordinate activities of patient care (patient is present);
approximately 30 minutes
S0221 Medical conference by a physician with interdisciplinary team of
health professionals or representatives of community agencies to
coordinate activities of patient care (patient is present);
approximately 60 minutes
S0250 Comprehensive geriatric assessment and treatment planning
performed by assessment team
S0255 Hospice referral visit (advising patient and family of care options)
performed by nurse, social worker, or other designated staff
S0257 Counseling and discussion regarding advance directives or end of
life care planning and decisions, with patient and/or surrogate (list
separately in addition to code for appropriate evaluation and
management service)
S0260 History and physical (outpatient or office) related to surgical
procedure (list separately in addition to code for appropriate
evaluation and management service)
S0265 Genetic counseling, under physician supervision, each 15 minutes
S0270 Physician management of patient home care, standard monthly case
rate (per 30 days)
S0271 Physician management of patient home care, hospice monthly case
rate (per 30 days)
S0272 Physician management of patient home care, episodic care monthly
case rate (per 30 days)
S0273 Physician visit at member’s home, outside of a capitation
arrangement
S0274 Nurse practitioner visit at member’s home, outside of a capitation
arrangement
S0280 Medical home program, comprehensive care coordination and
planning, initial plan
S0281 Medical home program, comprehensive care coordination and
planning, maintenance of plan
S0285 Colonoscopy consultation performed prior to a screening
colonoscopy procedure
S0302 Completed Early Periodic Screening Diagnosis and Treatment
(EPSDT) service (list in addition to code for appropriate evaluation
and management service)
S0310 Hospitalist services (list separately in addition to code for
appropriate evaluation and management service)
S0311 Comprehensive management and care coordination for advanced
illness, per calendar month
S0315 Disease management program; initial assessment and initiation of
the program
S0316 Disease management program; follow-up/reassessment
S0317 Disease management program; per diem
S0320 Telephone calls by a registered nurse to a disease management
program member for monitoring purposes; per month
S0340 Lifestyle modification program for management of coronary artery
disease, including all supportive services; first quarter/stage
S0341 Lifestyle modification program for management of coronary artery
disease, including all supportive services; second or third
quarter/stage
S0342 Lifestyle modification program for management of coronary artery
disease, including all supportive services; fourth quarter/stage
S0353 Treatment planning and care coordination management for cancer,
 initial treatment
S0354 Treatment planning and care coordination management for cancer,
established patient with a change of regimen
S0390 Routine foot care; removal and/or trimming of corns, calluses and/or
nails and preventive maintenance in specific medical conditions
(e.g., diabetes), per visit
S0395 Impression casting of a foot performed by a practitioner other than
the manufacturer of the orthotic
S0400 Global fee for extracorporeal shock wave lithotripsy treatment of
kidney stone(s)

Vision Supplies
S0500 Disposable contact lens, per lens
S0504 Single vision prescription lens (safety, athletic, or sunglass), per lens
S0506 Bifocal vision prescription lens (safety, athletic, or sunglass), per
lens
S0508 Trifocal vision prescription lens (safety, athletic, or sunglass), per
lens
S0510 Non-prescription lens (safety, athletic, or sunglass), per lens
S0512 Daily wear specialty contact lens, per lens
S0514 Color contact lens, per lens
S0515 Scleral lens, liquid bandage device, per lens
S0516 Safety eyeglass frames
S0518 Sunglasses frames
S0580 Polycarbonate lens (list this code in addition to the basic code for
the lens)
S0581 Nonstandard lens (list this code in addition to the basic code for the
lens)
S0590 Integral lens service, miscellaneous services reported separately
S0592 Comprehensive contact lens evaluation
S0595 Dispensing new spectacle lenses for patient supplied frame
S0596 Phakic intraocular lens for correction of refractive error

Screening and Examinations

 S0601 Screening proctoscopy
S0610 Annual gynecological examination, new patient ♀
S0612 Annual gynecological examination, established patient ♀
S0613 Annual gynecological examination; clinical breast examination
without pelvic evaluation ♀
S0618 Audiometry for hearing aid evaluation to determine the level and
degree of hearing loss
S0620 Routine ophthalmological examination including refraction; new
patient
Many non-Medicare vision plans may require code for routine
encounter, no complaints
S0621 Routine ophthalmological examination including refraction;
established patient
Many non-Medicare vision plans may require code for routine
encounter, no complaints
S0622 Physical exam for college, new or established patient (list
separately) in addition to appropriate evaluation and management
code

Provider Services and Supplies

S0630 Removal of sutures; by a physician other than the physician who
originally closed the wound
S0800 Laser in situ keratomileusis (LASIK)

Figure 48 Phototherapeutic keratectomy (PRK).

S0810 Photorefractive keratectomy (PRK)

S0812 Phototherapeutic keratectomy (PTK)
S1001 Deluxe item, patient aware (list in addition to code for basic item)
S1002 Customized item (list in addition to code for basic item)
S1015 IV tubing extension set
S1016 Non-PVC (polyvinyl chloride) intravenous administration set, for
use with drugs that are not stable in PVC (e.g., paclitaxel)
S1030 Continuous noninvasive glucose monitoring device, purchase (for
physician interpretation of data, use CPT code)
S1031 Continuous noninvasive glucose monitoring device, rental,
including sensor, sensor replacement, and download to monitor (for
physician interpretation of data, use CPT code)
S1034 Artificial pancreas device system (e.g., low glucose suspend (LGS)
feature) including continuous glucose monitor, blood glucose
device, insulin pump and computer algorithm that communicates
with all of the devices
S1035 Sensor; invasive (e.g., subcutaneous), disposable, for use with
artificial pancreas device system
S1036 Transmitter; external, for use with artificial pancreas device system
S1037 Receiver (monitor); external, for use with artificial pancreas device
system
S1040 Cranial remolding orthosis, pediatric, rigid, with soft interface
material, custom fabricated, includes fitting and adjustment(s)
S1091 Stent, non-coronary, temporary, with delivery system (propel)
S2053 Transplantation of small intestine and liver allografts
S2054 Transplantation of multivisceral organs
S2055 Harvesting of donor multivisceral organs, with preparation and
maintenance of allografts; from cadaver donor
S2060 Lobar lung transplantation
S2061 Donor lobectomy (lung) for transplantation, living donor
S2065 Simultaneous pancreas kidney transplantation
S2066 Breast reconstruction with gluteal artery perforator (GAP) flap,
including harvesting of the flap, microvascular transfer, closure of
donor site and shaping the flap into a breast, unilateral ♀
S2067 Breast reconstruction of a single breast with “stacked” deep inferior
epigastric perforator (DIEP) flap(s) and/or gluteal artery perforator
(GAP) flap(s), including harvesting of the flap(s), microvascular
transfer, closure of donor site(s) and shaping the flap into a breast,
 unilateral ♀
S2068 Breast reconstruction with deep inferior epigastric perforator (DIEP)
flap, or superficial inferior epigastric artery (SIEA) flap, including
harvesting of the flap, microvascular transfer, closure of donor site
and shaping the flap into a breast, unilateral ♀
S2070 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with
endoscopic laser treatment of ureteral calculi (includes ureteral
catheterization)
S2079 Laparoscopic esophagomyotomy (Heller type)
S2080 Laser-assisted uvulopalatoplasty (LAUP)
S2083 Adjustment of gastric band diameter via subcutaneous port by
injection or aspiration of saline

Figure 49 Gastric band.

S2095 Transcatheter occlusion or embolization for tumor destruction,

percutaneous, any method, using yttrium-90 microspheres
S2102 Islet cell tissue transplant from pancreas; allogeneic
S2103 Adrenal tissue transplant to brain
S2107 Adoptive immunotherapy i.e. development of specific anti-tumor
reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of
treatment
S2112 Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte
cells)
S2115 Osteotomy, periacetabular, with internal fixation
S2117 Arthroereisis, subtalar
S2118 Metal-on-metal total hip resurfacing, including acetabular and
femoral components
S2120 Low density lipoprotein (LDL) apheresis using heparin-induced
extracorporeal LDL precipitation
S2140 Cord blood harvesting for transplantation, allogeneic
S2142 Cord blood-derived stem cell transplantation, allogeneic
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
S2152 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
S2202 Echosclerotherapy
S2205 Minimally invasive direct coronary artery bypass surgery involving
minithoracotomy or mini-sternotomy surgery, performed under
direct vision; using arterial graft(s), single coronary arterial graft
S2206 Minimally invasive direct coronary artery bypass surgery involving
minithoracotomy or mini-sternotomy surgery, performed under
direct vision; using arterial graft(s), two coronary arterial grafts
S2207 Minimally invasive direct coronary artery bypass surgery involving
minithoracotomy or mini-sternotomy surgery, performed under
direct vision; using venous graft only, single coronary venous graft
S2208 Minimally invasive direct coronary artery bypass surgery involving
minithoracotomy or mini-sternotomy surgery, performed under
direct vision; using single arterial and venous graft(s), single venous
graft
S2209 Minimally invasive direct coronary artery bypass surgery involving
minithoracotomy or mini-sternotomy surgery, performed under
direct vision; using two arterial grafts and single venous graft

S2225 Myringotomy, laser-assisted

S2230 Implantation of magnetic component of semi-implantable hearing
device on ossicles in middle ear
S2235 Implantation of auditory brain stem implant
S2260 Induced abortion, 17 to 24 weeks ♀
S2265 Induced abortion, 25 to 28 weeks ♀
S2266 Induced abortion, 29 to 31 weeks ♀
S2267 Induced abortion, 32 weeks or greater ♀
S2300 Arthroscopy, shoulder, surgical; with thermally-induced
capsulorrhaphy
S2325 Hip core decompression
Coding Clinic: 2017, Q3, P1
S2340 Chemodenervation of abductor muscle(s) of vocal cord
S2341 Chemodenervation of adductor muscle(s) of vocal cord
S2342 Nasal endoscopy for post-operative debridement following
functional endoscopic sinus surgery, nasal and/or sinus cavity(s),
unilateral or bilateral
S2348 Decompression procedure, percutaneous, of nucleus pulpous of
intervertebral disc, using radiofrequency energy, single or multiple
levels, lumbar
S2350 Diskectomy, anterior, with decompression of spinal cord and/or
nerve root(s), including osteophytectomy; lumbar, single interspace
S2351 Diskectomy, anterior, with decompression of spinal cord and/or
nerve root(s) including osteophytectomy; lumbar, each additional
interspace (list separately in addition to code for primary procedure)
S2400 Repair, congenital diaphragmatic hernia in the fetus using temporary
tracheal occlusion, procedure performed in utero ♀
S2401 Repair, urinary tract obstruction in the fetus, procedure performed in
utero ♀
S2402 Repair, congenital cystic adenomatoid malformation in the fetus,
procedure performed in utero ♀
S2403 Repair, extralobar pulmonary sequestration in the fetus, procedure
performed in utero ♀
S2404 Repair, myelomeningocele in the fetus, procedure performed in
utero ♀
S2405 Repair of sacrococcygeal teratoma in the fetus, procedure performed
in utero ♀
S2409 Repair, congenital malformation of fetus, procedure performed in
utero, not otherwise classified ♀
 S2411 Fetoscopic laser therapy for treatment of twin-to-twin transfusion
syndrome
S2900 Surgical techniques requiring use of robotic surgical system (list
separately in addition to code for primary procedure)
Coding Clinic: 2010, Q2, P6
S3000 Diabetic indicator; retinal eye exam, dilated, bilateral
S3005 Performance measurement, evaluation of patient self assessment,
depression
S3600 STAT laboratory request (situations other than S3601)
S3601 Emergency STAT laboratory charge for patient who is homebound
or residing in a nursing facility
❂ S3620 Newborn metabolic screening panel, includes test kit, postage and
the laboratory tests specified by the state for inclusion in this panel
(e.g., galactose; hemoglobin, electrophoresis; hydroxyprogesterone,
17-D; phenylalanine (PKU); and thyroxine, total)
S3630 Eosinophil count, blood, direct
S3645 HIV-1 antibody testing of oral mucosal transudate
S3650 Saliva test, hormone level; during menopause ♀
S3652 Saliva test, hormone level; to assess preterm labor risk ♀
S3655 Antisperm antibodies test (immunobead) ♀
S3708 Gastrointestinal fat absorption study
S3722 Dose optimization by area under the curve (AUC) analysis, for
infusional 5-fluorouracil

Genetic Testing
S3800 Genetic testing for amyotrophic lateral sclerosis (ALS)
S3840 DNA analysis for germline mutations of the RET proto-oncogene
for susceptibility to multiple endocrine neoplasia type 2
S3841 Genetic testing for retinoblastoma
S3842 Genetic testing for von Hippel-Lindau disease
S3844 DNA analysis of the connexin 26 gene (GJB2) for susceptibility to
congenital, profound deafness
S3845 Genetic testing for alpha-thalassemia
S3846 Genetic testing for hemoglobin E betathalassemia
 S3849 Genetic testing for Niemann-Pick disease
S3850 Genetic testing for sickle cell anemia
S3852 DNA analysis for APOE epilson 4 allele for susceptibility to
Alzheimer’s disease
S3853 Genetic testing for myotonic muscular dystrophy
S3854 Gene expression profiling panel for use in the management of breast
cancer treatment ♀
S3861 Genetic testing, sodium channel, voltage-gated, type V, alpha
subunit (SCN5A) and variants for suspected Brugada syndrome
S3865 Comprehensive gene sequence analysis for hypertrophic
cardiomyopathy
S3866 Genetic analysis for a specific gene mutation for hypertrophic
cardiomyopathy (HCM) in an individual with a known HCM
mutation in the family
S3870 Comparative genomic hybridization (CGH) microarray testing for
developmental delay, autism spectrum disorder and/or intellectual
disability

Other Tests
S3900 Surface electromyography (EMG)
S3902 Ballistrocardiogram
S3904 Masters two step
Bill on paper. Requires a report.

Obstetric and Fertility Services

S4005 Interim labor facility global (labor occurring but not resulting in
delivery) ♀
S4011 In vitro fertilization; including but not limited to identification and
incubation of mature oocytes, fertilization with sperm, incubation of
embryo(s), and subsequent visualization for determination of
development ♀
S4013 Complete cycle, gamete intrafallopian transfer (GIFT), case rate ♀
S4014 Complete cycle, zygote intrafallopian transfer (ZIFT), case rate ♀
S4015 Complete in vitro fertilization cycle, not otherwise specified, case
rate ♀
 S4016 Frozen in vitro fertilization cycle, case rate ♀
S4017 Incomplete cycle, treatment cancelled prior to stimulation, case rate
♀
S4018 Frozen embryo transfer procedure cancelled before transfer, case
rate ♀
S4020 In vitro fertilization procedure cancelled before aspiration, case rate
♀
S4021 In vitro fertilization procedure cancelled after aspiration, case rate ♀
S4022 Assisted oocyte fertilization, case rate ♀
S4023 Donor egg cycle, incomplete, case rate ♀
S4025 Donor services for in vitro fertilization (sperm or embryo), case rate
S4026 Procurement of donor sperm from sperm bank ♂
S4027 Storage of previously frozen embryos ♀
S4028 Microsurgical epididymal sperm aspiration (MESA) ♂
S4030 Sperm procurement and cryopreservation services; initial visit ♂
S4031 Sperm procurement and cryopreservation services; subsequent visit
♂
S4035 Stimulated intrauterine insemination (IUI), case rate ♀
S4037 Cryopreserved embryo transfer, case rate ♀
S4040 Monitoring and storage of cryopreserved embryos, per 30 days ♀
S4042 Management of ovulation induction (interpretation of diagnostic
tests and studies, non-face-to-face medical management of the
patient), per cycle ♀
S4981 Insertion of levonorgestrel-releasing intrauterine system ♀
S4989 Contraceptive intrauterine device (e.g., Progestasert IUD), including
implants and supplies ♀

Therapeutic Substances and Medications

S4990 Nicotine patches, legend
S4991 Nicotine patches, non-legend
S4993 Contraceptive pills for birth control ♀
Only billed by Family Planning Clinics
S4995 Smoking cessation gum
S5000 Prescription drug, generic
 S5001 Prescription drug, brand name

Figure 50 IUD.

S5010 5% dextrose and 0.45% normal saline, 1000 ml

S5012 5% dextrose with potassium chloride, 1000 ml
S5013 5% dextrose/0.45% normal saline with potassium chloride and
magnesium sulfate, 1000 ml
S5014 5% dextrose/0.45% normal saline with potassium chloride and
magnesium sulfate, 1500 ml

Home Care Services

S5035 Home infusion therapy, routine service of infusion device (e.g.,
pump maintenance)
S5036 Home infusion therapy, repair of infusion device (e.g., pump repair)
S5100 Day care services, adult; per 15 minutes
S5101 Day care services, adult; per half day
S5102 Day care services, adult; per diem
S5105 Day care services, center-based; services not included in program
fee, per diem
S5108 Home care training to home care client, per 15 minutes
S5109 Home care training to home care client, per session
S5110 Home care training, family; per 15 minutes
S5111 Home care training, family; per session
S5115 Home care training, non-family; per 15 minutes
S5116 Home care training, non-family; per session
 S5120 Chore services; per 15 minutes
S5121 Chore services; per diem
S5125 Attendant care services; per 15 minutes
S5126 Attendant care services; per diem
S5130 Homemaker service, NOS; per 15 minutes
S5131 Homemaker service, NOS; per diem
S5135 Companion care, adult (e.g., IADL/ADL); per 15 minutes
S5136 Companion care, adult (e.g., IADL/ADL); per diem
S5140 Foster care, adult; per diem
S5141 Foster care, adult; per month
S5145 Foster care, therapeutic, child; per diem
S5146 Foster care, therapeutic, child; per month
S5150 Unskilled respite care, not hospice; per 15 minutes
S5151 Unskilled respite care, not hospice; per diem
S5160 Emergency response system; installation and testing
S5161 Emergency response system; service fee, per month (excludes
installation and testing)
S5162 Emergency response system; purchase only
S5165 Home modifications; per service
S5170 Home delivered meals, including preparation; per meal
S5175 Laundry service, external, professional; per order
S5180 Home health respiratory therapy, initial evaluation
S5181 Home health respiratory therapy, NOS, per diem
S5185 Medication reminder service, non-face-to-face; per month
S5190 Wellness assessment, performed by non-physician
S5199 Personal care item, NOS, each

Home Infusion Therapy

S5497 Home infusion therapy, catheter care/maintenance, not otherwise
classified; includes administrative services, professional pharmacy
services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem
S5498 Home infusion therapy, catheter care/maintenance, simple (single
 lumen), includes administrative services, professional pharmacy
services, care coordination and all necessary supplies and
equipment, (drugs and nursing visits coded separately), per diem
S5501 Home infusion therapy, catheter care/maintenance, complex (more
than one lumen), includes administrative services, professional
pharmacy services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem
S5502 Home infusion therapy, catheter care/maintenance, implanted access
device, includes administrative services, professional pharmacy
services, care coordination, and all necessary supplies and
equipment, (drugs and nursing visits coded separately), per diem
(use this code for interim maintenance of vascular access not
currently in use)
S5517 Home infusion therapy, all supplies necessary for restoration of
catheter patency or declotting
S5518 Home infusion therapy, all supplies necessary for catheter repair
S5520 Home infusion therapy, all supplies (including catheter) necessary
for a peripherally inserted central venous catheter (PICC) line
insertion
Bill on paper. Requires a report.
S5521 Home infusion therapy, all supplies (including catheter) necessary
for a midline catheter insertion
S5522 Home infusion therapy, insertion of peripherally inserted central
venous catheter (PICC), nursing services only (no supplies or
catheter included)
S5523 Home infusion therapy, insertion of midline central venous catheter,
nursing services only (no supplies or catheter included)

Insulin Services
S5550 Insulin, rapid onset, 5 units
S5551 Insulin, most rapid onset (Lispro or Aspart); 5 units
S5552 Insulin, intermediate acting (NPH or Lente); 5 units
S5553 Insulin, long acting; 5 units
S5560 Insulin delivery device, reusable pen; 1.5 ml size
S5561 Insulin delivery device, reusable pen; 3 ml size
S5565 Insulin cartridge for use in insulin delivery device other than pump;
150 units
 S5566 Insulin cartridge for use in insulin delivery device other than pump;
300 units

Figure 51 Nova pen.

S5570 Insulin delivery device, disposable pen (including insulin); 1.5 ml

size
S5571 Insulin delivery device, disposable pen (including insulin); 3 ml size

Imaging
S8030 Scleral application of tantalum ring(s) for localization of lesions for
proton beam therapy
S8035 Magnetic source imaging
S8037 Magnetic resonance cholangiopancreatography (MRCP)
S8040 Topographic brain mapping
S8042 Magnetic resonance imaging (MRI), low-field
S8055 Ultrasound guidance for multifetal pregnancy reduction(s), technical
component (only to be used when the physician doing the reduction
procedure does not perform the ultrasound, guidance is included in
the CPT code for multifetal pregnancy reduction - 59866) ♀
S8080 Scintimammography (radioimmunoscintigraphy of the breast),
unilateral, including supply of radiopharmaceutical ♀
S8085 Fluorine-18 fluorodeoxyglucose (F-18 FDG) imaging using dual-
head coincidence detection system (nondedicated PET scan)
S8092 Electron beam computed tomography (also known as ultrafast CT,
cine CT)

Assistive Breathing Supplies

S8096 Portable peak flow meter
S8097 Asthma kit (including but not limited to portable peak expiratory
flow meter, instructional video, brochure, and/or spacer)
S8100 Holding chamber or spacer for use with an inhaler or nebulizer;
without mask
S8101 Holding chamber or spacer for use with an inhaler or nebulizer; with
mask
S8110 Peak expiratory flow rate (physician services)
S8120 Oxygen contents, gaseous, 1 unit equals 1 cubic foot
S8121 Oxygen contents, liquid, 1 unit equals 1 pound
S8130 Interferential current stimulator, 2 channel
S8131 Interferential current stimulator, 4 channel
S8185 Flutter device
S8186 Swivel adapter
S8189 Tracheostomy supply, not otherwise classified
S8210 Mucus trap
Miscellaneous Supplies and Services
S8265 Haberman feeder for cleft lip/palate
S8270 Enuresis alarm, using auditory buzzer and/or vibration device
S8301 Infection control supplies, not otherwise specified
S8415 Supplies for home delivery of infant
S8420 Gradient pressure aid (sleeve and glove combination), custom made
S8421 Gradient pressure aid (sleeve and glove combination), ready made
S8422 Gradient pressure aid (sleeve), custom made, medium weight
S8423 Gradient pressure aid (sleeve), custom made, heavy weight
S8424 Gradient pressure aid (sleeve), ready made
S8425 Gradient pressure aid (glove), custom made, medium weight
S8426 Gradient pressure aid (glove), custom made, heavy weight
S8427 Gradient pressure aid (glove), ready made
S8428 Gradient pressure aid (gauntlet), ready made
S8429 Gradient pressure exterior wrap
S8430 Padding for compression bandage, roll
S8431 Compression bandage, roll
S8450 Splint, prefabricated, digit (specify digit by use of modifier)
S8451 Splint, prefabricated, wrist or ankle
S8452 Splint, prefabricated, elbow
S8460 Camisole, post-mastectomy
S8490 Insulin syringes (100 syringes, any size)
S8930 Electrical stimulation of auricular acupuncture points; each 15
minutes of personal one-on-one contact with the patient
S8940 Equestrian/Hippotherapy, per session
S8948 Application of a modality (requiring constant provider attendance)
to one or more areas; low-level laser; each 15 minutes
S8950 Complex lymphedema therapy, each 15 minutes
S8990 Physical or manipulative therapy performed for maintenance rather
than restoration
S8999 Resuscitation bag (for use by patient on artificial respiration during
power failure or other catastrophic event)
S9001 Home uterine monitor with or without associated nursing services ♀
S9007 Ultrafiltration monitor
S9024 Paranasal sinus ultrasound
S9025 Omnicardiogram/cardiointegram
S9034 Extracorporeal shockwave lithotripsy for gall stones (if performed
with ERCP, use 43265)
S9055 Procuren or other growth factor preparation to promote wound
healing
S9056 Coma stimulation per diem
S9061 Home administration of aerosolized drug therapy (e.g.,
pentamidine); administrative services, professional pharmacy
services, care coordination, all necessary supplies and equipment
(drugs and nursing visits coded separately), per diem
S9083 Global fee urgent care centers
S9088 Services provided in an urgent care center (list in addition to code
for service)
S9090 Vertebral axial decompression, per session
S9097 Home visit for wound care
S9098 Home visit, phototherapy services (e.g., Bili-Lite), including
equipment rental, nursing services, blood draw, supplies, and other
services, per diem
S9110 Telemonitoring of patient in their home, including all necessary
equipment; computer system, connections, and software;
maintenance; patient education and support; per month
S9117 Back school, per visit
S9122 Home health aide or certified nurse assistant, providing care in the
home; per hour
S9123 Nursing care, in the home; by registered nurse, per hour (use for
general nursing care only, not to be used when CPT codes 99500-
99602 can be used)
S9124 Nursing care, in the home; by licensed practical nurse, per hour
S9125 Respite care, in the home, per diem
S9126 Hospice care, in the home, per diem
S9127 Social work visit, in the home, per diem
S9128 Speech therapy, in the home, per diem
 S9129 Occupational therapy, in the home, per diem
S9131 Physical therapy; in the home, per diem
S9140 Diabetic management program, follow-up visit to non-MD provider
S9141 Diabetic management program, follow-up visit to MD provider
S9145 Insulin pump initiation, instruction in initial use of pump (pump not
included)
S9150 Evaluation by ocularist
S9152 Speech therapy, re-evaluation

Home Management of Pregnancy

S9208 Home management of preterm labor, including administrative
services, professional pharmacy services, care coordination, and all
necessary supplies or equipment (drugs and nursing visits coded
separately), per diem (do not use this code with any home infusion
per diem code) ♀
S9209 Home management of preterm premature rupture of membranes
(PPROM), including administrative services, professional pharmacy
services, care coordination, and all necessary supplies or equipment
(drugs and nursing visits coded separately), per diem (do not use
this code with any home infusion per diem code) ♀
S9211 Home management of gestational hypertension, includes
administrative services, professional pharmacy services, care
coordination, and all necessary supplies and equipment (drugs and
nursing visits coded separately); per diem (do not use this code with
any home infusion per diem code) ♀
S9212 Home management of postpartum hypertension, includes
administrative services, professional pharmacy services, care
coordination, and all necessary supplies and equipment (drugs and
nursing visits coded separately), per diem (do not use this code with
any home infusion per diem code) ♀
S9213 Home management of preeclampsia, includes administrative
services, professional pharmacy services, care coordination, and all
necessary supplies and equipment (drugs and nursing services coded
separately); per diem (do not use this code with any home infusion
per diem code) ♀
S9214 Home management of gestational diabetes, includes administrative
services, professional pharmacy services, care coordination, and all
 necessary supplies and equipment (drugs and nursing visits coded
separately); per diem (do not use this code with any home infusion
per diem code) ♀

Home Infusion Therapy

S9325 Home infusion therapy, pain management infusion; administrative
services, professional pharmacy services, care coordination, and all
necessary supplies and equipment, (drugs and nursing visits coded
separately), per diem (do not use this code with S9326, S9327 or
S9328)
S9326 Home infusion therapy, continuous (twenty-four hours or more)
pain management infusion; administrative services, professional
pharmacy services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem
S9327 Home infusion therapy, intermittent (less than twenty-four hours)
pain management infusion; administrative services, professional
pharmacy services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem
S9328 Home infusion therapy, implanted pump pain management infusion;
administrative services, professional pharmacy services, care
coordination, and all necessary supplies and equipment (drugs and
nursing visits coded separately), per diem
S9329 Home infusion therapy, chemotherapy infusion; administrative
services, professional pharmacy services, care coordination, and all
necessary supplies and equipment (drugs and nursing visits coded
separately), per diem (do not use this code with S9330 or S9331)
S9330 Home infusion therapy, continuous (twenty-four hours or more)
chemotherapy infusion; administrative services, professional
pharmacy services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem
S9331 Home infusion therapy, intermittent (less than twenty-four hours)
chemotherapy infusion; administrative services, professional
pharmacy services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem

S9335 Home therapy, hemodialysis; administrative services, professional

pharmacy services, care coordination, and all necessary supplies and
equipment (drugs and nursing services coded separately), per diem
S9336 Home infusion therapy, continuous anticoagulant infusion therapy
 (e.g., heparin), administrative services, professional pharmacy
services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem
S9338 Home infusion therapy, immunotherapy, administrative services,
professional pharmacy services, care coordination, and all necessary
supplies and equipment (drug and nursing visits coded separately),
per diem
S9339 Home therapy; peritoneal dialysis, administrative services,
professional pharmacy services, care coordination and all necessary
supplies and equipment (drugs and nursing visits coded separately),
per diem
S9340 Home therapy; enteral nutrition; administrative services,
professional pharmacy services, care coordination, and all necessary
supplies and equipment (enteral formula and nursing visits coded
separately), per diem
S9341 Home therapy; enteral nutrition via gravity; administrative services,
professional pharmacy services, care coordination, and all necessary
supplies and equipment (enteral formula and nursing visits coded
separately), per diem
S9342 Home therapy; enteral nutrition via pump; administrative services,
professional pharmacy services, care coordination, and all necessary
supplies and equipment (enteral formula and nursing visits coded
separately), per diem
S9343 Home therapy; enteral nutrition via bolus; administrative services,
professional pharmacy services, care coordination, and all necessary
supplies and equipment (enteral formula and nursing visits coded
separately), per diem
S9345 Home infusion therapy, anti-hemophilic agent infusion therapy (e.g.,
Factor VIII); administrative services, professional pharmacy
services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem

S9346 Home infusion therapy, alpha-1-proteinase inhibitor (e.g., Prolastin);

administrative services, professional pharmacy services, care
coordination, and all necessary supplies and equipment (drugs and
nursing visits coded separately), per diem
S9347 Home infusion therapy, uninterrupted, long-term, controlled rate
intravenous or subcutaneous infusion therapy (e.g., Epoprostenol);
administrative services, professional pharmacy services, care
coordination, and all necessary supplies and equipment (drugs and
 nursing visits coded separately), per diem
S9348 Home infusion therapy, sympathomimetic/inotropic agent infusion
therapy (e.g., Dobutamine); administrative services, professional
pharmacy services, care coordination, all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem
S9349 Home infusion therapy, tocolytic infusion therapy; administrative
services, professional pharmacy services, care coordination, and all
necessary supplies and equipment (drugs and nursing visits coded
separately), per diem
S9351 Home infusion therapy, continuous or intermittent anti-emetic
infusion therapy; administrative services, professional pharmacy
services, care coordination, and all necessary supplies and
equipment (drugs and visits coded separately), per diem
S9353 Home infusion therapy, continuous insulin infusion therapy;
administrative services, professional pharmacy services, care
coordination, and all necessary supplies and equipment (drugs and
nursing visits coded separately), per diem
S9355 Home infusion therapy, chelation therapy; administrative services,
professional pharmacy services, care coordination, and all necessary
supplies and equipment (drugs and nursing visits coded separately),
per diem
S9357 Home infusion therapy, enzyme replacement intravenous therapy
(e.g., Imiglucerase); administrative services, professional pharmacy
services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem

S9359 Home infusion therapy, anti-tumor necrosis factor intravenous

therapy (e.g., Infliximab); administrative services, professional
pharmacy services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem
S9361 Home infusion therapy, diuretic intravenous therapy; administrative
services, professional pharmacy services, care coordination, and all
necessary supplies and equipment (drugs and nursing visits coded
separately), per diem
S9363 Home infusion therapy, anti-spasmotic therapy; administrative
services, professional pharmacy services, care coordination, and all
necessary supplies and equipment (drugs and nursing visits coded
separately), per diem
S9364 Home infusion therapy, total parenteral nutrition (TPN);
administrative services, professional pharmacy services, care
 coordination, and all necessary supplies and equipment including
standard TPN formula (lipids, specialty amino acid formulas, drugs
other than in standard formula, and nursing visits coded separately)
per diem (do not use with home infusion codes S9365-S9368 using
daily volume scales)
S9365 Home infusion therapy, total parenteral nutrition (TPN); one liter
per day, administrative services, professional pharmacy services,
care coordination, and all necessary supplies and equipment
including standard TPN formula (lipids, specialty amino acid
formulas, drugs other than in standard formula and nursing visits
coded separately), per diem
S9366 Home infusion therapy, total parenteral nutrition (TPN); more than
one liter but no more than two liters per day, administrative services,
professional pharmacy services, care coordination, and all necessary
supplies and equipment including standard TPN formula (lipids,
specialty amino acid formulas, drugs other than in standard formula
and nursing visits coded separately), per diem
S9367 Home infusion therapy, total parenteral nutrition (TPN); more than
two liters but no more than three liters per day, administrative
services, professional pharmacy services, care coordination, and all
necessary supplies and equipment including standard TPN formula
(lipids, specialty amino acid formulas, drugs other than in standard
formula and nursing visits coded separately), per diem
S9368 Home infusion therapy, total parenteral nutrition (TPN); more than
three liters per day, administrative services, professional pharmacy
services, care coordination, and all necessary supplies and
equipment (including standard TPN formula; lipids, specialty amino
acid formulas, drugs other than in standard formula and nursing
visits coded separately), per diem
S9370 Home therapy, intermittent anti-emetic injection therapy;
administrative services, professional pharmacy services, care
coordination, and all necessary supplies and equipment (drugs and
nursing visits coded separately), per diem
S9372 Home therapy; intermittent anticoagulant injection therapy (e.g.,
heparin); administrative services, professional pharmacy services,
care coordination, and all necessary supplies and equipment (drugs
and nursing visits coded separately), per diem (do not use this code
for flushing of infusion devices with heparin to maintain patency)
S9373 Home infusion therapy, hydration therapy; administrative services,
professional pharmacy services, care coordination, and all necessary
 supplies and equipment (drugs and nursing visits coded separately),
per diem (do not use with hydration therapy codes S9374-S9377
using daily volume scales)
S9374 Home infusion therapy, hydration therapy; one liter per day,
administrative services, professional pharmacy services, care
coordination, and all necessary supplies and equipment (drugs and
nursing visits coded separately), per diem
S9375 Home infusion therapy, hydration therapy; more than one liter but
no more than two liters per day, administrative services, professional
pharmacy services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem
S9376 Home infusion therapy, hydration therapy; more than two liters but
no more than three liters per day, administrative services,
professional pharmacy services, care coordination, and all necessary
supplies and equipment (drugs and nursing visits coded separately),
per diem
S9377 Home infusion therapy, hydration therapy; more than three liters per
day, administrative services, professional pharmacy services, care
coordination, and all necessary supplies (drugs and nursing visits
coded separately), per diem
S9379 Home infusion therapy, infusion therapy, not otherwise classified;
administrative services, professional pharmacy services, care
coordination, and all necessary supplies and equipment (drugs and
nursing visits coded separately), per diem

Miscellaneous Supplies and Services

S9381 Delivery or service to high risk areas requiring escort or extra
protection, per visit
S9401 Anticoagulation clinic, inclusive of all services except laboratory
tests, per session
S9430 Pharmacy compounding and dispensing services
S9432 Medical foods for non-inborn errors of metabolism
S9433 Medical food nutritionally complete, administered orally, providing
100% of nutritional intake
S9434 Modified solid food supplements for inborn errors of metabolism
S9435 Medical foods for inborn errors of metabolism
S9436 Childbirth preparation/Lamaze classes, non-physician provider, per
session ♀
S9437 Childbirth refresher classes, nonphysician provider, per session ♀
S9438 Cesarean birth classes, non-physician provider, per session ♀
S9439 VBAC (vaginal birth after cesarean) classes, non-physician
provider, per session ♀
S9441 Asthma education, non-physician provider, per session
S9442 Birthing classes, non-physician provider, per session ♀
S9443 Lactation classes, non-physician provider, per session ♀
S9444 Parenting classes, non-physician provider, per session
S9445 Patient education, not otherwise classified, non-physician provider,
individual, per session
S9446 Patient education, not otherwise classified, non-physician provider,
group, per session
S9447 Infant safety (including CPR) classes, non-physician provider, per
session
S9449 Weight management classes, nonphysician provider, per session
S9451 Exercise classes, non-physician provider, per session
S9452 Nutrition classes, non-physician provider, per session
S9453 Smoking cessation classes, nonphysician provider, per session
S9454 Stress management classes, nonphysician provider, per session
S9455 Diabetic management program, group session
S9460 Diabetic management program, nurse visit
S9465 Diabetic management program, dietitian visit
S9470 Nutritional counseling, dietitian visit
S9472 Cardiac rehabilitation program, nonphysician provider, per diem
S9473 Pulmonary rehabilitation program, non-physician provider, per diem
S9474 Enterostomal therapy by a registered nurse certified in enterostomal
therapy, per diem
S9475 Ambulatory setting substance abuse treatment or detoxification
services, per diem

S9476 Vestibular rehabilitation program, nonphysician provider, per diem

S9480 Intensive outpatient psychiatric services, per diem
S9482 Family stabilization services, per 15 minutes
S9484 Crisis intervention mental health services, per hour
 S9485 Crisis intervention mental health services, per diem

Home Therapy Services

S9490 Home infusion therapy, corticosteroid infusion; administrative
services, professional pharmacy services, care coordination, and all
necessary supplies and equipment (drugs and nursing visits coded
separately), per diem
S9494 Home infusion therapy, antibiotic, antiviral, or antifungal therapy;
administrative services, professional pharmacy services, care
coordination, and all necessary supplies and equipment (drugs and
nursing visits coded separately) per diem (do not use this code with
home infusion codes for hourly dosing schedules S9497-S9504)
S9497 Home infusion therapy, antibiotic, antiviral, or antifungal therapy;
once every 3 hours; administrative services, professional pharmacy
services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem
S9500 Home infusion therapy, antibiotic, antiviral, or antifungal therapy;
once every 24 hours; administrative services, professional pharmacy
services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem
S9501 Home infusion therapy, antibiotic, antiviral, or antifungal therapy;
once every 12 hours; administrative services, professional pharmacy
services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem
S9502 Home infusion therapy, antibiotic, antiviral, or antifungal therapy;
once every 8 hours, administrative services, professional pharmacy
services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem
S9503 Home infusion therapy, antibiotic, antiviral, or antifungal; once
every 6 hours; administrative services, professional pharmacy
services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem
S9504 Home infusion therapy, antibiotic, antiviral, or antifungal; once
every 4 hours; administrative services, professional pharmacy
services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem
S9529 Routine venipuncture for collection of specimen(s), single home
bound, nursing home, or skilled nursing facility patient
S9537 Home therapy; hematopoietic hormone injection therapy (e.g.,
 erythropoietin, G-CSF, GM-CSF); administrative services,
professional pharmacy services, care coordination, and all necessary
supplies and equipment (drugs and nursing visits coded separately),
per diem

S9538 Home transfusion of blood product(s); administrative services,

professional pharmacy services, care coordination, and all necessary
supplies and equipment (blood products, drugs, and nursing visits
coded separately), per diem
S9542 Home injectable therapy; not otherwise classified, including
administrative services, professional pharmacy services, care
coordination, and all necessary supplies and equipment (drugs and
nursing visits coded separately), per diem
S9558 Home injectable therapy; growth hormone, including administrative
services, professional pharmacy services, care coordination, and all
necessary supplies and equipment (drugs and nursing visits coded
separately), per diem
S9559 Home injectable therapy; interferon, including administrative
services, professional pharmacy services, care coordination, and all
necessary supplies and equipment (drugs and nursing visits coded
separately), per diem
S9560 Home injectable therapy; hormonal therapy (e.g., Leuprolide,
Goserelin), including administrative services, professional
pharmacy services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem
S9562 Home injectable therapy, palivizumab, including administrative
services, professional pharmacy services, care coordination, and all
necessary supplies and equipment (drugs and nursing visits coded
separately), per diem
S9590 Home therapy, irrigation therapy (e.g., sterile irrigation of an organ
or anatomical cavity); including administrative services,
professional pharmacy services, care coordination, and all necessary
supplies and equipment (drugs and nursing visits coded separately),
per diem
S9810 Home therapy; professional pharmacy services for provision of
infusion, specialty drug administration, and/or disease state
management, not otherwise classified, per hour (do not use this code
with any per diem code)
Other Services and Fees
S9900 Services by journal-listed Christian Science Practitioner for the
purpose of healing, per diem
S9901 Services by a journal-listed Christian Science nurse, per hour
S9960 Ambulance service, conventional air service, nonemergency
transport, one way (fixed wing)
S9961 Ambulance service, conventional air service, nonemergency
transport, one way (rotary wing)
S9970 Health club membership, annual
S9975 Transplant related lodging, meals and transportation, per diem
S9976 Lodging, per diem, not otherwise classified
S9977 Meals, per diem, not otherwise specified
S9981 Medical records copying fee, administrative
S9982 Medical records copying fee, per page
S9986 Not medically necessary service (patient is aware that service not
medically necessary)
S9988 Services provided as part of a Phase I clinical trial
S9989 Services provided outside of the United States of America (list in
addition to code(s) for services(s))
S9990 Services provided as part of a Phase II clinical trial
S9991 Services provided as part of a Phase III clinical trial
S9992 Transportation costs to and from trial location and local
transportation costs (e.g., fares for taxicab or bus) for clinical trial
participant and one caregiver/companion
S9994 Lodging costs (e.g., hotel charges) for clinical trial participant and
one caregiver/companion
S9996 Meals for clinical trial participant and one caregiver/companion
S9999 Sales tax

TEMPORARY NATIONAL CODES ESTABLISHED BY

MEDICAID (T1000-T9999)
Not Valid For Medicare
T1000 Private duty/independent nursing service(s) - licensed, up to 15
 minutes
T1001 Nursing assessment/evaluation
T1002 RN services, up to 15 minutes
T1003 LPN/LVN services, up to 15 minutes
T1004 Services of a qualified nursing aide, up to 15 minutes
T1005 Respite care services, up to 15 minutes
T1006 Alcohol and/or substance abuse services, family/couple counseling
T1007 Alcohol and/or substance abuse services, treatment plan
development and/or modification
T1009 Child sitting services for children of the individual receiving alcohol
and/or substance abuse services
T1010 Meals for individuals receiving alcohol and/or substance abuse
services (when meals not included in the program)
T1012 Alcohol and/or substance abuse services, skills development
T1013 Sign language or oral interpretive services, per 15 minutes
T1014 Telehealth transmission, per minute, professional services bill
separately
T1015 Clinic visit/encounter, all-inclusive
T1016 Case Management, each 15 minutes
T1017 Targeted Case Management, each 15 minutes
T1018 School-based individualized education program (IEP) services,
bundled
T1019 Personal care services, per 15 minutes, not for an inpatient or
resident of a hospital, nursing facility, ICF/MR or IMD, part of the
individualized plan of treatment (code may not be used to identify
services provided by home health aide or certified nurse assistant)
T1020 Personal care services, per diem, not for an inpatient or resident of a
hospital, nursing facility, ICF/MR or IMD, part of the individualized
plan of treatment (code may not be used to identify services
provided by home health aide or certified nurse assistant)
T1021 Home health aide or certified nurse assistant, per visit

T1022 Contracted home health agency services, all services provided under
contract, per day
T1023 Screening to determine the appropriateness of consideration of an
individual for participation in a specified program, project or
 treatment protocol, per encounter
T1024 Evaluation and treatment by an integrated, specialty team contracted
to provide coordinated care to multiple or severely handicapped
children, per encounter
T1025 Intensive, extended multidisciplinary services provided in a clinic
setting to children with complex medical, physical, mental and
psychosocial impairments, per diem
T1026 Intensive, extended multidisciplinary services provided in a clinic
setting to children with complex medical, physical, medical and
psychosocial impairments, per hour
T1027 Family training and counseling for child development, per 15
minutes
T1028 Assessment of home, physical and family environment, to determine
suitability to meet patient’s medical needs
T1029 Comprehensive environmental lead investigation, not including
laboratory analysis, per dwelling
T1030 Nursing care, in the home, by registered nurse, per diem
T1031 Nursing care, in the home, by licensed practical nurse, per diem
▶ T1032 Services performed by a doula birth worker, per 15 minutes
▶ T1033 Services performed by a doula birth worker, per diem
T1040 Medicaid certified community behavioral health clinic services, per
diem
T1041 Medicaid certified community behavioral health clinic services, per
month
T1502 Administration of oral, intramuscular and/or subcutaneous
medication by health care agency/professional, per visit
T1503 Administration of medication, other than oral and/or injectable, by a
health care agency/professional, per visit

T1505 Electronic medication compliance management device, includes all

components and accessories, not otherwise classified
T1999 Miscellaneous therapeutic items and supplies, retail purchases, not
otherwise classified; identify product in “remarks”
T2001 Non-emergency transportation; patient attendant/escort
T2002 Non-emergency transportation; per diem
T2003 Non-emergency transportation; encounter/trip
T2004 Non-emergency transport; commercial carrier, multi-pass
T2005 Non-emergency transportation: stretcher van
T2007 Transportation waiting time, air ambulance and non-emergency
vehicle, one-half (1/2) hour increments
T2010 Preadmission screening and resident review (PASRR) level I
identification screening, per screen
T2011 Preadmission screening and resident review (PASRR) level II
evaluation, per evaluation
T2012 Habilitation, educational, waiver; per diem
T2013 Habilitation, educational, waiver; per hour
T2014 Habilitation, prevocational, waiver; per diem
T2015 Habilitation, prevocational, waiver; per hour
T2016 Habilitation, residential, waiver; per diem
T2017 Habilitation, residential, waiver; 15 minutes
T2018 Habilitation, supported employment, waiver; per diem
T2019 Habilitation, supported employment, waiver; per 15 minutes
T2020 Day habilitation, waiver; per diem
T2021 Day habilitation, waiver; per 15 minutes
T2022 Case management, per month
T2023 Targeted case management; per month
T2024 Service assessment/plan of care development, waiver
T2025 Waiver services; not otherwise specified (NOS)
T2026 Specialized childcare, waiver; per diem
T2027 Specialized childcare, waiver; per 15 minutes

T2028 Specialized supply, not otherwise specified, waiver

T2029 Specialized medical equipment, not otherwise specified, waiver
T2030 Assisted living, waiver; per month
T2031 Assisted living; waiver, per diem
T2032 Residential care, not otherwise specified (NOS), waiver; per month
T2033 Residential care, not otherwise specified (NOS), waiver; per diem
T2034 Crisis intervention, waiver; per diem
T2035 Utility services to support medical equipment and assistive
technology/devices, waiver
T2036 Therapeutic camping, overnight, waiver; each session
T2037 Therapeutic camping, day, waiver; each session
T2038 Community transition, waiver; per service
T2039 Vehicle modifications, waiver; per service
T2040 Financial management, self-directed, waiver; per 15 minutes
T2041 Supports brokerage, self-directed, waiver; per 15 minutes
T2042 Hospice routine home care; per diem
T2043 Hospice continuous home care; per hour
T2044 Hospice inpatient respite care; per diem
T2045 Hospice general inpatient care; per diem
T2046 Hospice long term care, room and board only; per diem
T2047 Habilitation, prevocational, waiver; per 15 minutes
T2048 Behavioral health; long-term care residential (non-acute care in a
residential treatment program where stay is typically longer than 30
days), with room and board, per diem
T2049 Non-emergency transportation; stretcher van, mileage; per mile
T2101 Human breast milk processing, storage and distribution only ♀
T4521 Adult sized disposable incontinence product, brief/diaper, small,
each
IOM: 100-03, 4, 280.1
T4522 Adult sized disposable incontinence product, brief/diaper, medium,
each
IOM: 100-03, 4, 280.1
T4523 Adult sized disposable incontinence product, brief/diaper, large,
each
IOM: 100-03, 4, 280.1
T4524 Adult sized disposable incontinence product, brief/diaper, extra
large, each
IOM: 100-03, 4, 280.1
T4525 Adult sized disposable incontinence product, protective
underwear/pull-on, small size, each
IOM: 100-03, 4, 280.1
T4526 Adult sized disposable incontinence product, protective
underwear/pull-on, medium size, each
IOM: 100-03, 4, 280.1
Adult sized disposable incontinence product, protective
T4527 underwear/pull-on, large size, each
IOM: 100-03, 4, 280.1
T4528 Adult sized disposable incontinence product, protective
underwear/pull-on, extra large size, each
IOM: 100-03, 4, 280.1
T4529 Pediatric sized disposable incontinence product, brief/diaper,
small/medium size, each
IOM: 100-03, 4, 280.1
T4530 Pediatric sized disposable incontinence product, brief/diaper, large
size, each
IOM: 100-03, 4, 280.1
T4531 Pediatric sized disposable incontinence product, protective
underwear/pull-on, small/medium size, each
IOM: 100-03, 4, 280.1
T4532 Pediatric sized disposable incontinence product, protective
underwear/pull-on, large size, each
IOM: 100-03, 4, 280.1
T4533 Youth sized disposable incontinence product, brief/diaper, each
IOM: 100-03, 4, 280.1
T4534 Youth sized disposable incontinence product, protective
underwear/pull-on, each
IOM: 100-03, 4, 280.1
T4535 Disposable liner/shield/guard/pad/undergarment, for incontinence,
each
IOM: 100-03, 4, 280.1
T4536 Incontinence product, protective underwear/pull-on, reusable, any
size, each
IOM: 100-03, 4, 280.1
T4537 Incontinence product, protective underpad, reusable, bed size, each
IOM: 100-03, 4, 280.1
T4538 Diaper service, reusable diaper, each diaper
IOM: 100-03, 4, 280.1
T4539 Incontinence product, diaper/brief, reusable, any size, each
IOM: 100-03, 4, 280.1
T4540 Incontinence product, protective underpad, reusable, chair size, each
IOM: 100-03, 4, 280.1
 T4541 Incontinence product, disposable underpad, large, each
T4542 Incontinence product, disposable underpad, small size, each
T4543 Adult sized disposable incontinence product, protective brief/diaper,
above extra large, each
IOM: 100-03, 4, 280.1
T4544 Adult sized disposable incontinence product, protective
underwear/pull-on, above extra large, each
IOM: 100-03, 4, 280.1
T4545 Incontinence product, disposable, penile wrap, each ♂
T5001 Positioning seat for persons with special orthopedic needs, supply,
not otherwise specified
T5999 Supply, not otherwise specified

CORONAVIRUS DIAGNOSTIC PANEL (U0001-U0005)

U0001 CDC 2019 novel coronavirus (2019-nCoV) real-time RT-PCR
diagnostic panel A

U0002 2019-nCoV coronavirus, SARS-CoV-2/2019-nCoV (COVID-19),

any technique, multiple types or subtypes (includes all targets), non-
CDC A

U0003 Infectious agent detection by nucleic acid (DNA or RNA); severe

acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
(Coronavirus disease [COVID-19]), amplified probe technique,
making use of high throughput technologies as described by CMS-
2020-01-R A

U0004 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19),

any technique, multiple types or subtypes (includes all targets), non-
CDC, making use of high throughput technologies as described by
CMS-2020-01-R A

U0005 Infectious agent detection by nucleic acid (DNA or RNA); severe

acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
(Coronavirus disease [COVID-19]), amplified probe technique,
CDC or non-CDC, making use of high throughput technologies,
completed within 2 calendar days from date of specimen collection
(list separately in addition to either HCPCS code U0003 or U0004)
as described by CMS-2020-01-R2 A
VISION SERVICES (V0000-V2999)
Frames
❂ V2020 Frames, purchases A

Includes cost of frame/replacement and dispensing fee. One unit of

service represents one pair of eyeglass frames.
IOM: 100-02, 15, 120
V2025 Deluxe frame E1

Not a benefit. Billing deluxe framessubmit V2020 on one line;

V2025 on second line.
IOM: 100-04, 1, 30.3.5

If a CPT procedure code for supply of spectacles or a permanent prosthesis is

reported, recode with the specific lens type listed below.

Single Vision Lenses

✽ V2100 Sphere, single vision, plano to plus or minus 4.00, per lens
A
✽ V2101 Sphere, single vision, plus or minus 4.12 to plus or minus 7.00d, per
lens A

✽ V2102 Sphere, single vision, plus or minus 7.12 to plus or minus 20.00d,
per lens A

✽ V2103 Spherocylinder, single vision, plano to plus or minus 4.00d sphere,

.12 to 2.00d cylinder, per lens A

✽ V2104 Spherocylinder, single vision, plano to plus or minus 4.00d sphere,

2.12 to 4.00d cylinder, per lens A

✽ V2105 Spherocylinder, single vision, plano to plus or minus 4.00d sphere,

4.25 to 6.00d cylinder, per lens A

✽ V2106 Spherocylinder, single vision, plano to plus or minus 4.00d sphere,

over 6.00d cylinder, per lens A

✽ V2107 Spherocylinder, single vision, plus or minus 4.25 to plus or minus

7.00 sphere, .12 to 2.00d cylinder, per lens A

✽ V2108 Spherocylinder, single vision, plus or minus 4.25d to plus or minus

7.00d sphere, 2.12 to 4.00d cylinder, per lens A

✽ V2109 Spherocylinder, single vision, plus or minus 4.25 to plus or minus

7.00d sphere, 4.25 to 6.00d cylinder, per lens A
 ✽ V2110 Sperocylinder, single vision, plus or minus 4.25 to 7.00d sphere,
over 6.00d cylinder, per lens A

✽ V2111 Spherocylinder, single vision, plus or minus 7.25 to plus or minus

12.00d sphere, .25 to 2.25d cylinder, per lens A

✽ V2112 Spherocylinder, single vision, plus or minus 7.25 to plus or minus

12.00d sphere, 2.25d to 4.00d cylinder, per lens A

✽ V2113 Spherocylinder, single vision, plus or minus 7.25 to plus or minus

12.00d sphere, 4.25 to 6.00d cylinder, per lens A

✽ V2114 Spherocylinder, single vision, sphere over plus or minus 12.00d, per
lens A

✽ V2115 Lenticular, (myodisc), per lens, single vision A

✽ V2118 Aniseikonic lens, single vision A

❂ V2121 Lenticular lens, per lens, single A

IOM: 100-02, 15, 120; 100-04, 3, 10.4

✽ V2199 Not otherwise classified, single vision lens A

Bill on paper. Requires report of type of single vision lens and

optical lab invoice.

Bifocal Lenses
✽ V2200 Sphere, bifocal, plano to plus or minus 4.00d, per lens
A
✽ V2201 Sphere, bifocal, plus or minus 4.12 to plus or minus 7.00d, per lens
A

✽ V2202 Sphere, bifocal, plus or minus 7.12 to plus or minus 20.00d, per lens
A

✽ V2203 Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, .12 to

2.00d cylinder, per lens A

✽ V2204 Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, 2.12 to

4.00d cylinder, per lens A

✽ V2205 Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, 4.25 to

6.00d cylinder, per lens A

✽ V2206 Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, over

6.00d cylinder, per lens A

✽ V2207 Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d

sphere, .12 to 2.00d cylinder, per lens A

✽ V2208 Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d

sphere, 2.12 to 4.00d cylinder, per lens A
 ✽ V2209 Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d
sphere, 4.25 to 6.00d cylinder, per lens A

✽ V2210 Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d

sphere, over 6.00d cylinder, per lens A

✽ V2211 Spherocylinder, bifocal, plus or minus 7.25 to plus or minus 12.00d

sphere, .25 to 2.25d cylinder, per lens A

✽ V2212 Spherocylinder, bifocal, plus or minus 7.25 to plus or minus 12.00d

sphere, 2.25 to 4.00d cylinder, per lens A

✽ V2213 Spherocylinder, bifocal, plus or minus 7.25 to plus or minus 12.00d

sphere, 4.25 to 6.00d cylinder, per lens A

✽ V2214 Spherocylinder, bifocal, sphere over plus or minus 12.00d, per lens
A

✽ V2215 Lenticular (myodisc), per lens, bifocal A

✽ V2218 Aniseikonic, per lens, bifocal A

✽ V2219 Bifocal seg width over 28 mm A

✽ V2220 Bifocal add over 3.25d A

❂ V2221 Lenticular lens, per lens, bifocal A

IOM: 100-02, 15, 120; 100-04, 3, 10.4

✽ V2299 Specialty bifocal (by report) A

Bill on paper. Requires report of type of specialty bifocal lens and

optical lab invoice.

Trifocal Lenses
✽ V2300 Sphere, trifocal, plano to plus or minus 4.00d, per lens
A
✽ V2301 Sphere, trifocal, plus or minus 4.12 to plus or minus 7.00d per lens
A

✽ V2302 Sphere, trifocal, plus or minus 7.12 to plus or minus 20.00, per lens
A

✽ V2303 Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, .12 to

2.00d cylinder, per lens A

✽ V2304 Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, 2.25-

4.00d cylinder, per lens A

✽ V2305 Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, 4.25

to 6.00 cylinder, per lens A

✽ V2306 Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, over

6.00d cylinder, per lens A
 ✽ V2307 Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d
sphere, .12 to 2.00d cylinder, per lens A

✽ V2308 Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d

sphere, 2.12 to 4.00d cylinder, per lens A

✽ V2309 Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d

sphere, 4.25 to 6.00d cylinder, per lens A

✽ V2310 Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d

sphere, over 6.00d cylinder, per lens A

✽ V2311 Spherocylinder, trifocal, plus or minus 7.25 to plus or minus 12.00d

sphere, .25 to 2.25d cylinder, per lens A

✽ V2312 Spherocylinder, trifocal, plus or minus 7.25 to plus or minus 12.00d

sphere, 2.25 to 4.00d cylinder, per lens A

✽ V2313 Spherocylinder, trifocal, plus or minus 7.25 to plus or minus 12.00d

sphere, 4.25 to 6.00d cylinder, per lens A

✽ V2314 Spherocylinder, trifocal, sphere over plus or minus 12.00d, per lens
A

✽ V2315 Lenticular, (myodisc), per lens, trifocal A

✽ V2318 Aniseikonic lens, trifocal A

✽ V2319 Trifocal seg width over 28 mm A

✽ V2320 Trifocal add over 3.25d A

❂ V2321 Lenticular lens, per lens, trifocal A

IOM: 100-02, 15, 120; 100-04, 3, 10.4

✽ V2399 Specialty trifocal (by report) A

Bill on paper. Requires report of type of trifocal lens and optical lab
invoice.

Variable Asphericity/Sphericity Lenses

✽ V2410 Variable asphericity lens, single vision, full field, glass or plastic,
per lens A

✽ V2430 Variable asphericity lens, bifocal, full field, glass or plastic, per lens
A

✽ V2499 Variable sphericity lens, other type A

Bill on paper. Requires report of other ptical lab invoice.

Contact Lenses
If a CPT procedure code for supply of contact lens is reported, recode with
specific lens type listed below (per lens).
✽ V2500 Contact lens, PMMA, spherical, per lens A

Requires prior authorization for patients under age 21.

✽ V2501 Contact lens, PMMA, toric or prism ballast, per lens A

Requires prior authorization for clients under age 21.

✽ V2502 Contact lens, PMMA, bifocal, per lens A

Requires prior authorization for clients under age 21. Bill on paper.
Requires optical lab invoice.
✽ V2503 Contact lens PMMA, color vision deficiency, per lens A

Requires prior authorization for clients under age 21. Bill on paper.
Requires optical lab invoice.
✽ V2510 Contact lens, gas permeable, spherical, per lens A

Requires prior authorization for clients under age 21.

✽ V2511 Contact lens, gas permeable, toric, prism ballast, per lens
A
Requires prior authorization for clients under age 21.
✽ V2512 Contact lens, gas permeable, bifocal, per lens A

Requires prior authorization for clients under age 21.

✽ V2513 Contact lens, gas permeable, extended wear, per lens A

Requires prior authorization for clients under age 21.

❂ V2520 Contact lens, hydrophilic, spherical, per lens A

Requires prior authorization for clients under age 21.

IOM: 100-03, 1, 80.1; 100-03, 1, 80.4
❂ V2521 Contact lens, hydrophilic, toric, or prism ballast, per lens
A
Requires prior authorization for clients under age 21.
IOM: 100-03, 1, 80.1; 100-03, 1, 80.4
❂ V2522 Contact lens, hydrophilic, bifocal, per lens A

Requires prior authorization for clients under age 21.

IOM: 100-03, 1, 80.1; 100-03, 1, 80.4
❂ V2523 Contact lens, hydrophilic, extended wear, per lens A

Requires prior authorization for clients under age 21.

IOM: 100-03, 1, 80.1; 100-03, 1, 80.4
❂ V2524 Contact lens, hydrophilic, spherical, photochromic additive, per lens
A
✽ V2530 Contact lens, scleral, gas impermeable, per lens (for contact lens
 modification, see 92325) A

Requires prior authorization for clients under age 21.

❂ V2531 Contact lens, scleral, gas permeable, per lens (for contact lens
modification, see 92325) A

Requires prior authorization for clients under age 21. Bill on paper.
Requires optical lab invoice.
IOM: 100-03, 1, 80.5
✽ V2599 Contact lens, other type A

Requires prior authorization for clients under age 21. Bill on paper.
Requires report of other type of contact lens and optical invoice.

Low Vision Aids

If a CPT procedure code for supply of low vision aid is reported, recode with
specific systems listed below.
✽ V2600 Hand held low vision aids and other nonspectacle mounted aids
A

Requires prior authorization.

✽ V2610 Single lens spectacle mounted low vision aids A

Requires prior authorization.

✽ V2615 Telescopic and other compound lens system, including distance
vision telescopic, near vision telescopes and compound microscopic
lens system A

Requires prior authorization. Bill on paper. Requires optical lab

invoice.

Prosthetic Eye
❂ V2623 Prosthetic eye, plastic, custom A

DME regional carrier. Requires prior authorization. Bill on paper.

Requires optical lab invoice.
✽ V2624 Polishing/resurfacing of ocular prosthesis A

Requires prior authorization. Bill on paper. Requires optical lab

invoice.
✽ V2625 Enlargement of ocular prosthesis A

Requires prior authorization. Bill on paper. Requires optical lab

invoice.
✽ V2626 Reduction of ocular prosthesis A
 Requires prior authorization. Bill on paper. Requires optical lab
invoice.
❂ V2627 Scleral cover shell A

DME regional carrier

Requires prior authorization. Bill on paper. Requires optical lab
invoice.
IOM: 100-03, 4, 280.2
✽ V2628 Fabrication and fitting of ocular conformer A

Requires prior authorization. Bill on paper. Requires optical lab

invoice.
✽ V2629 Prosthetic eye, other type A

Requires prior authorization. Bill on paper. Requires optical lab

invoice.

Intraocular Lenses
❂ V2630 Anterior chamber intraocular lens N1 N

IOM: 100-02, 15, 120

❂ V2631 Iris supported intraocular lens N1 N

IOM: 100-02, 15, 120

❂ V2632 Posterior chamber intraocular lens N1 N

IOM: 100-02, 15, 120

Figure 52 Posterior intraocular lens.

Miscellaneous Vision Services

✽ V2700 Balance lens, per lens A
V2702 Deluxe lens feature E1

IOM: 100-02, 15, 120; 100-04, 3, 10.4

✽ V2710 Slab off prism, glass or plastic, per lens A

✽ V2715 Prism, per lens A

✽ V2718 Press-on lens, Fresnel prism, per lens A

✽ V2730 Special base curve, glass or plastic, per lens A

❂ V2744 Tint, photochromatic, per lens A

Requires prior authorization.

IOM: 100-02, 15, 120; 100-04, 3, 10.4
❂ V2745 Addition to lens, tint, any color, solid, gradient or equal, excludes
photochroatic, any lens material, per lens A

Includes photochromatic lenses (V2744) used as sunglasses, which

are prescribed in addition to regular prosthetic lenses for aphakic
patient will be denied as not medically necessary.
IOM: 100-02, 15, 120; 100-04, 3, 10.4
❂ V2750 Anti-reflective coating, per lens A

Requires prior authorization.

IOM: 100-02, 15, 120; 100-04, 3, 10.4
❂ V2755 U-V lens, per lens A

IOM: 100-02, 15, 120; 100-04, 3, 10.4

✽ V2756 Eye glass case E1

✽ V2760 Scratch resistant coating, per lens E1

❂ V2761 Mirror coating, any type, solid, gradient or equal, any lens material,
per lens B

IOM: 100-02, 15, 120; 100-04, 3, 10.4

❂ V2762 Polarization, any lens material, per lens E1

IOM: 100-02, 15, 120; 100-04, 3, 10.4

✽ V2770 Occluder lens, per lens A

Requires prior authorization.

✽ V2780 Oversize lens, per lens A

Requires prior authorization.

✽ V2781 Progressive lens, per lens B

Requires prior authorization.

❂ V2782 Lens, index 1.54 to 1.65 plastic or 1.60 to 1.79 glass, excludes
polycarbonate, per lens A
 Do not bill in addition to V2784
IOM: 100-02, 15, 120; 100-04, 3, 10.4
❂ V2783 Lens, index greater than or equal to 1.66 plastic or greater than or
equal to 1.80 glass, excludes polycarbonate, per lens A

Do not bill in addition to V2784

IOM: 100-02, 15, 120; 100-04, 3, 10.4
❂ V2784 Lens, polycarbonate or equal, any index, per lens A

Covered only for patients with functional vision in one eye-in this
situation, an impact-resistant material is covered for both lenses if
eyeglasses are covered. Claims with V2784 that do not meet this
coverage criterion will be denied as not medically necessary.
IOM: 100-02, 15, 120; 100-04, 3, 10.4
✽ V2785 Processing, preserving and transporting corneal tissue
F4 F
For ASC, bill on paper. Must attach eye bank invoice to
claim.
For Hospitals, bill charges for corneal tissue to receive cost based
reimbursement.
IOM: 100-4, 4, 200.1
❂ V2786 Specialty occupational multifocal lens, per lens E1

IOM: 100-02, 15, 120; 100-04, 3, 10.4

V2787 Astigmatism correcting function of intraocular lens E1

Medicare Statute 1862(a)(7)

V2788 Presbyopia correcting function of intraocular lens E1

Medicare Statute 1862a7

✽ V2790 Amniotic membrane for surgical reconstruction, per procedure
N1 N
✽ V2797 Vision supply, accessory and/or service component of another
HCPCS vision code E1

✽ V2799 Vision item or service, miscellaneous A

Bill on paper. Requires report of miscellaneous service and optical

lab invoice.

HEARING SERVICES (V5000-V5999)

These codes are for non-physician services.

Assessments and Evaluations

 V5008 Hearing screening E1

IOM: 100-02, 16, 90

V5010 Assessment for hearing aid E1

Medicare Statute 1862a7

V5011 Fitting/orientation/checking of hearing aid E1

Medicare Statute 1862a7

V5014 Repair/modification of a hearing aid E1

Medicare Statute 1862a7

V5020 Conformity evaluation E1

Medicare Statute 1862a7

Monaural Hearing Aid

V5030 Hearing aid, monaural, body worn, air conduction E1

Medicare Statute 1862a7

V5040 Hearing aid, monaural, body worn, bone conduction E1

Medicare Statute 1862a7

V5050 Hearing aid, monaural, in the ear E1

Medicare Statute 1862a7

V5060 Hearing aid, monaural, behind the ear E1

Medicare Statute 1862a7

Miscellaneous Services and Supplies

V5070 Glasses, air conduction E1

Medicare Statute 1862a7

V5080 Glasses, bone conduction E1

Medicare Statute 1862a7

V5090 Dispensing fee, unspecified hearing aid E1

Medicare Statute 1862a7

V5095 Semi-implantable middle ear hearing prosthesis E1

Medicare Statute 1862a7

V5100 Hearing aid, bilateral, body worn E1

Medicare Statute 1862a7

V5110 Dispensing fee, bilateral E1

Medicare Statute 1862a7

Hearing Aids
V5120 Binaural, body E1

Medicare Statute 1862a7

V5130 Binaural, in the ear E1

Medicare Statute 1862a7

V5140 Binaural, behind the ear E1

Medicare Statute 1862a7

V5150 Binaural, glasses E1

Medicare Statute 1862a7

V5160 Dispensing fee, binaural E1

Medicare Statute 1862a7

V5171 Hearing aid, contralateral routing device, monaural, in the ear (ITE)
E1
Medicare Statute 1862a7
V5172 Hearing aid, contralateral routing device, monaural, in the canal
(ITC) E1

Medicare Statute 1862a7

V5181 Hearing aid, contralateral routing device, monaural, behind the ear
(BTE) E1

Medicare Statute 1862a7

V5190 Hearing aid, contralateral routing, monaural, glasses E1

Medicare Statute 1862a7

V5200 Dispensing fee, contralateral, monaural E1

Medicare Statute 1862a7

V5211 Hearing aid, contralateral routing system, binaural, ITE/ITE E1

Medicare Statute 1862a7

V5212 Hearing aid, contralateral routing system, binaural, ITE/ITC E1

Medicare Statute 1862a7

V5213 Hearing aid, contralateral routing system, binaural, ITE/BTE E1

Medicare Statute 1862a7

V5214 Hearing aid, contralateral routing system, binaural, ITC/ITC E1

Medicare Statute 1862a7

V5215 Hearing aid, contralateral routing system, binaural, ITC/BTE E1

Medicare Statute 1862a7

V5221 Hearing aid, contralateral routing system, binaural, BTE/BTE E1

Medicare Statute 1862a7

V5230 Hearing aid, contralateral routing system, binaural, glasses E1

Medicare Statute 1862a7

V5240 Dispensing fee, contralateral routing system, binaural E1

Medicare Statute 1862a7

V5241 Dispensing fee, monaural hearing aid, any type E1

Medicare Statute 1862a7

V5242 Hearing aid, analog, monaural, CIC (completely in the ear canal)
E1
Medicare Statute 1862a7
V5243 Hearing aid, analog, monaural, ITC (in the canal) E1

Medicare Statute 1862a9

V5244 Hearing aid, digitally programmable analog, monaural, CIC E1

Medicare Statute 1862a7

V5245 Hearing aid, digitally programmable, analog, monaural, ITC E1

Medicare Statute 1862a7

V5246 Hearing aid, digitally programmable analog, monaural, ITE (in the
ear) E1

Medicare Statute 1862a7

V5247 Hearing aid, digitally programmable analog, monaural, BTE (behind
the ear) E1

Medicare Statute 1862a7

V5248 Hearing aid, analog, binaural, CIC E1

Medicare Statute 1862a7

V5249 Hearing aid, analog, binaural, ITC E1

Medicare Statute 1862a7

V5250 Hearing aid, digitally programmable analog, binaural, CIC E1

Medicare Statute 1862a7

V5251 Hearing aid, digitally programmable analog, binaural, ITC E1

Medicare Statute 1862a7

V5252 Hearing aid, digitally programmable, binaural, ITE E1

Medicare Statute 1862a7

V5253 Hearing aid, digitally programmable, binaural, BTE E1

Medicare Statute 1862a7

 V5254 Hearing aid, digital, monaural, CIC E1

Medicare Statute 1862a7

V5255 Hearing aid, digital, monaural, ITC E1

Medicare Statute 1862a7

V5256 Hearing aid, digital, monaural, ITE E1

Medicare Statute 1862a7

V5257 Hearing aid, digital, monaural, BTE E1

Medicare Statute 1862a7

V5258 Hearing aid, digital, binaural, CIC E1

Medicare Statute 1862a7

V5259 Hearing aid, digital, binaural, ITC E1

Medicare Statute 1862a7

V5260 Hearing aid, digital, binaural, ITE E1

Medicare Statute 1862a7

V5261 Hearing aid, digital, binaural, BTE E1

Medicare Statute 1862a7

V5262 Hearing aid, disposable, any type, monaural E1

Medicare Statute 1862a7

V5263 Hearing aid, disposable, any type, binaural E1

Medicare Statute 1862a7

V5264 Ear mold/insert, not disposable, any type E1

Medicare Statute 1862a7

V5265 Ear mold/insert, disposable, any type E1

Medicare Statute 1862a7

V5266 Battery for use in hearing device E1

Medicare Statute 1862a7

V5267 Hearing aid or assistive listening device/supplies/accessories, not
otherwise specified E1

Medicare Statute 1862a7

Assistive Listening Devices

V5268 Assistive listening device, telephone amplifier, any type E1

Medicare Statute 1862a7

V5269 Assistive listening device, alerting, any type E1
 Medicare Statute 1862a7
V5270 Assistive listening device, television amplifier, any type E1

Medicare Statute 1862a7

V5271 Assistive listening device, television caption decoder E1

Medicare Statute 1862a7

V5272 Assistive listening device, TDD E1

Medicare Statute 1862a7

V5273 Assistive listening device, for use with cochlear implant E1

Medicare Statute 1862a7

V5274 Assistive listening device, not otherwise specified E1

Medicare Statute 1862a7

V5275 Ear impression, each E1

Medicare Statute 1862a7

V5281 Assistive listening device, personal FM/DM system, monaural (1
receiver, transmitter, microphone), any type E1

Medicare Statute 1862a7

V5282 Assistive listening device, personal FM/DM system, binaural (2
receivers, transmitter, microphone), any type E1

Medicare Statute 1862a7

V5283 Assistive listening device, personal FM/DM neck, loop induction
receiver E1

Medicare Statute 1862a7

V5284 Assistive listening device, personal FM/DM, ear level receiver
E1
Medicare Statute 1862a7
V5285 Assistive listening device, personal FM/DM, direct audio input
receiver E1

Medicare Statute 1862a7

V5286 Assistive listening device, personal Bluetooth FM/DM receiver
E1

Medicare Statute 1862a7

V5287 Assistive listening device, personal FM/DM receiver, not otherwise
specified E1

Medicare Statute 1862a7

V5288 Assistive listening device, personal FM/DM transmitter assistive
listening device E1
 Medicare Statute 1862a7
V5289 Assistive listening device, personal FM/DM adapter/boot coupling
device for receiver, any type E1

Medicare Statute 1862a7

V5290 Assistive listening device, transmitter microphone, any type
E1
Medicare Statute 1862a7

Other Supllies and Miscellaneous Services

V5298 Hearing aid, not otherwise classified E1

Medicare Statute 1862a7

❂ V5299 Hearing service, miscellaneous B

IOM: 100-02, 16, 90

Repair/Modification
V5336 Repair/modification of augmentative communicative system or
device (excludes adaptive hearing aid) E1

Medicare Statute 1862a7

Speech, Language, and Pathology Screening

These codes are for non-physician services.
V5362 Speech screening E1

Medicare Statute 1862a7

V5363 Language screening E1

Medicare Statute 1862a7

V5364 Dysphagia screening E1

Medicare Statute 1862a7

◀ New Revised ✔ Reinstated deleted Deleted Not covered or valid by Medicare

❂ Special coverage instructions ✽ Carrier discretion Bill Part B MAC Bill DME MAC

MIPS Quantity Physician Quantity Hospital ♀ Female only ♂ Male only Age

DMEPOS A2-Z3 ASC Payment Indicator A-Y ASC Status Indicator Coding Clinic
 APPENDIX A
Jurisdiction List for DMEPOS HCPCS Codes
Deleted codes are valid for dates of service on or before the date of deletion. The jurisdiction list includes codes that are not
payable by Medicare. Please consult the Medicare contractor in whose jurisdiction a claim would be filed in order to
determine coverage under Medicare.
NOTE: All Local Carrier language has been changed to Part B MAC

HCPCS DESCRIPTION JURISDICTION

A4206 - A4209 Medical, Surgical, and Self- Part B MAC if incident to a physician’s service
Administered Injection Supplies (not separately payable). If other, DME MAC.
A4210 Needle Free Injection Device DME MAC
A4211 Medical, Surgical, and Self- Part B MAC if incident to a physician’s service
Administered Injection Supplies (not separately payable). If other, DME MAC.
A4213 - A4215 Medical, Surgical, and Self- Part B MAC if incident to a physician’s service
Administered Injection Supplies (not separately payable). If other, DME MAC.
A4216 - A4218 Saline Part B MAC if incident to a physician’s service
(not separately payable). If other, DME MAC.
A4221 - A4236 Self-Administered Injection and DME MAC
Diabetic Supplies
A4244 - A4250 Medical, Surgical, and Self- Part B MAC if incident to a physician’s service
Administered Injection Supplies (not separately payable). If other, DME MAC.
A4252 - A4259 Diabetic Supplies DME MAC
A4265 Paraffin Part B MAC if incident to a physician’s service
(not separately payable). If other, DME MAC.
A4280 Accessory for Breast Prosthesis DME MAC
A4281 - A4286 Accessory for Breast Pump DME MAC
A4305 - A4306 Disposable Drug Delivery System Part B MAC if incident to a physician’s service
(not separately payable). If other, DME MAC.
A4310 - A4358 Incontinence Supplies/Urinary Supplies If provided in the physician’s office for a
temporary condition, the item is incident to the
physician’s service & billed to the Part B
MAC.
If provided in the physician’s office or other
place of service for a permanent condition, the
item is a prosthetic device & billed to the
DME MAC.

A4360 - A4437 Urinary Supplies If provided in the physician’s office for a

temporary condition, the item is incident to the
physician’s service & billed to the Part B
MAC.
 If provided in the physician’s office or other
place of service for a permanent condition, the
item is a prosthetic device & billed to the
DME MAC.
A4450 - A4452 Tape; Adhesive Remover Part B MAC if incident to a physician’s service
(not separately payable), or if supply for
implanted prosthetic device. If other, DME
MAC.
A4453 Enema Catheter DME MAC
A4455-A4456 Tape; Adhesive Remover Part B MAC if incident to a physician’s service
(not separately payable), or if supply for
implanted prosthetic device. If other, DME
MAC.
A4458-A4459 Enema Bag/System DME MAC
A4461-A4463 Surgical Dressing Holders Part B MAC if incident to a physician’s service
(not separately payable). If other, DME MAC.
A4465 - A4467 Non-elastic Binder and Garment, Strap, DME MAC
Covering
A4481 Tracheostomy Supply Part B MAC if incident to a physician’s service
(not separately payable). If other, DME MAC.
A4483 Moisture Exchanger DME MAC
A4490 - A4510 Surgical Stockings DME MAC
A4520 Diapers DME MAC
A4553 - A4554 Underpads DME MAC
A4575 Topical Hyperbaric Oxygen Chamber, DME MAC
Disposable
A4595 TENS Supplies Part B MAC if incident to a physician’s service
(not separately payable). If other, DME MAC.
A4600 Sleeve for Intermittent Limb DME MAC
Compression Device
A4601-A4602 Lithium Replacement Batteries DME MAC
A4604 Tubing for Positive Airway Pressure DME MAC
Device
A4605 Tracheal Suction Catheter DME MAC
A4606 Oxygen Probe for Oximeter DME MAC
A4608 Transtracheal Oxygen Catheter DME MAC
A4611 - A4613 Oxygen Equipment Batteries and DME MAC
Supplies
A4614 Peak Flow Rate Meter Part B MAC if incident to a physician’s service
(not separately payable). If other, DME MAC.

A4615 - A4629 Oxygen & Tracheostomy Supplies Part B MAC if incident to a physician’s service
(not separately payable). If other, DME MAC.
A4630 - A4640 DME Supplies DME MAC
A4649 Miscellaneous Surgical Supplies Part B MAC if incident to a physician’s service
(not separately payable), or if supply for
 implanted prosthetic device or implanted
DME. If other, DME MAC.
A4651 - A4932 Supplies for ESRD DME MAC (not separately payable)
A5051 - A5093 Additional Ostomy Supplies If provided in the physician’s office for a
temporary condition, the item is incident to the
physician’s service & billed to the Part B
MAC.
If provided in the physician’s office or other
place of service for a permanent condition, the
item is a prosthetic device & billed to the
DME MAC.
A5102 - A5200 Additional Incontinence and Ostomy If provided in the physician’s office for a
Supplies temporary condition, the item is incident to the
physician’s service & billed to the Part B
MAC.
If provided in the physician’s office or other
place of service for a permanent condition, the
item is a prosthetic device & billed to the
DME MAC.
A5500 - A5514 Therapeutic Shoes DME MAC
A6000 Non-Contact Wound Warming Cover DME MAC
A6010-A6024 Surgical Dressing Part B MAC if incident to a physician’s service
(not separately payable) or if supply for
implanted prosthetic device or implanted
DME. If other, DME MAC.
A6025 Silicone Gel Sheet Part B MAC if incident to a physician’s service
(not separately payable) or if supply for
implanted prosthetic device or implanted
DME. If other, DME MAC.
A6154 - A6411 Surgical Dressing Part B MAC if incident to a physician’s service
(not separately payable) or if supply for
implanted prosthetic device or implanted
DME. If other, DME MAC.
A6412 Eye Patch Part B MAC if incident to a physician’s service
(not separately payable) or if supply for
implanted prosthetic device or implanted
DME. If other, DME MAC.
A6413 Adhesive Bandage Part B MAC if incident to a physician’s service
(not separately payable) or if supply for
implanted prosthetic device or implanted
DME. If other, DME MAC.
A6441 - A6457 Surgical Dressing Part B MAC if incident to a physician’s service
(not separately payable) or if supply for
implanted prosthetic device or implanted
DME. If other, DME MAC.
A6501 - A6512 Surgical Dressing Part B MAC if incident to a physician’s service
(not separately payable) or if supply for
implanted prosthetic device or implanted
DME. If other, DME MAC.
A6513 Compression Burn Mask DME MAC
A6530 - A6549 Compression Gradient Stockings DME MAC
A6550 Supplies for Negative Pressure Wound DME MAC
Therapy Electrical Pump
A7000 - A7002 Accessories for Suction Pumps DME MAC
A7003 - A7039 Accessories for Nebulizers, Aspirators DME MAC
and Ventilators
A7044 - A7047 Respiratory Accessories DME MAC
A7501-A7527 Tracheostomy Supplies DME MAC
A8000-A8004 Protective Helmets DME MAC
A9270 Noncovered Items or Services DME MAC
A9272 Disposable Wound Suction Pump DME MAC
A9273 Hot Water Bottles, Ice Caps or Collars, DME MAC
and Heat and/or Cold Wraps
A9274 - A9278 Glucose Monitoring DME MAC
A9279 Monitoring Feature/Device DME MAC
A9280 Alarm Device DME MAC
A9281 Reaching/Grabbing Device DME MAC
A9282 Wig DME MAC
A9283 Foot Off Loading Device DME MAC
A9284-A9286 Non-electric Spirometer, Inversion DME MAC
Devices and Hygienic Items
A9300 Exercise Equipment DME MAC
A9900 Miscellaneous DME Supply or Part B MAC if used with implanted DME. If
Accessory other, DME MAC.
A9901 Delivery DME MAC
A9999 Miscellaneous DME Supply or Part B MAC if used with implanted DME. If
Accessory other, DME MAC.
B4034 - B9999 Enteral and Parenteral Therapy DME MAC
E0100 - E0105 Canes DME MAC
E0110 - E0118 Crutches DME MAC
E0130 - E0159 Walkers DME MAC
E0160 - E0175 Commodes DME MAC
E0181 - E0199 Decubitus Care Equipment DME MAC
E0200 - E0239 Heat/Cold Applications DME MAC
E0240 - E0248 Bath and Toilet Aids DME MAC
E0249 Pad for Heating Unit DME MAC
E0250 - E0304 Hospital Beds DME MAC
E0305 - E0326 Hospital Bed Accessories DME MAC
E0328 - E0329 Pediatric Hospital Beds DME MAC
E0350 - E0352 Electronic Bowel Irrigation System DME MAC
E0370 Heel Pad DME MAC
E0371 - E0373 Decubitus Care Equipment DME MAC
E0424 - E0484 Oxygen and Related Respiratory DME MAC
Equipment
E0485 - E0486 Oral Device to Reduce Airway DME MAC
Collapsibility
E0487 Electric Spirometer DME MAC
E0500 IPPB Machine DME MAC
E0550 - E0585 Compressors/Nebulizers DME MAC
E0600 Suction Pump DME MAC
E0601 CPAP Device DME MAC
E0602 - E0604 Breast Pump DME MAC
E0605 Vaporizer DME MAC
E0606 Drainage Board DME MAC
E0607 Home Blood Glucose Monitor DME MAC
E0610 - E0615 Pacemaker Monitor DME MAC
E0617 External Defibrillator DME MAC
E0618 - E0619 Apnea Monitor DME MAC
E0620 Skin Piercing Device DME MAC
E0621 - E0636 Patient Lifts DME MAC
E0637 - E0642 Standing Devices/Lifts DME MAC
E0650 - E0676 Pneumatic Compressor and Appliances DME MAC
E0691 - E0694 Ultraviolet Light Therapy Systems DME MAC
E0700 Safety Equipment DME MAC
E0705 Transfer Board DME MAC
E0710 Restraints DME MAC
E0720 - E0745 Electrical Nerve Stimulators DME MAC
E0747 - E0748 Osteogenic Stimulators DME MAC

E0755-E0770 Stimulation Devices DME MAC

E0776 IV Pole DME MAC
E0779 - E0780 External Infusion Pumps DME MAC
E0781 Ambulatory Infusion Pump DME MAC
E0784 Infusion Pumps, insulin DME MAC
E0791 Parenteral Infusion Pump DME MAC
E0830 Ambulatory Traction Device DME MAC
E0840 - E0900 Traction Equipment DME MAC
E0910 - E0930 Trapeze/Fracture Frame DME MAC
E0935 - E0936 Passive Motion Exercise Device DME MAC
E0940 Trapeze Equipment DME MAC
E0941 Traction Equipment DME MAC
E0942 - E0945 Orthopedic Devices DME MAC
E0946 - E0948 Fracture Frame DME MAC
E0950 - E1298 Wheelchairs DME MAC
E1300 - E1310 Whirlpool Equipment DME MAC
E1352 - E1392 Additional Oxygen Related Equipment DME MAC
E1399 Miscellaneous DME Part B MAC if implanted DME. If other, DME
MAC.
E1405 - E1406 Additional Oxygen Equipment DME MAC
E1500 - E1625 Artificial Kidney Machines and DME MAC (not separately payable)
Accessories
E1630 - E1699 Artifical Kidney Machines and DME MAC (not separately payable)
Accessories
E1700 - E1702 TMJ Device and Supplies DME MAC
E1800 - E1841 Dynamic Flexion Devices DME MAC
E1902 Communication Board DME MAC
E2000 Gastric Suction Pump DME MAC
E2100 - E2101 Blood Glucose Monitors with Special DME MAC
Features
E2120 Pulse Generator for Tympanic Treatment DME MAC
of Inner Ear
E2201 - E2398 Wheelchair Accessories DME MAC
E2402 Negative Pressure Wound Therapy DME MAC
Pump
E2500 - E2599 Speech Generating Device DME MAC
E2601 - E2633 Wheelchair Cushions and Accessories DME MAC
E8000 - E8002 Gait Trainers DME MAC
G0333 Dispensing Fee DME MAC
J0120 - J1094 Injection Part B MAC if incident to a physician’s service
or used in an implanted infusion pump. If
other, DME MAC.
J1100 - J2786 Injection Part B MAC if incident to a physician’s service
or used in an implanted infusion pump. If
other, DME MAC.
J2788 - J3570 Injection Part B MAC if incident to a physician’s service
or used in an implanted infusion pump. If
other, DME MAC.
J7030 - J7131 Miscellaneous Drugs and Solutions Part B MAC if incident to a physician’s service
or used in an implanted infusion pump. If
other, DME MAC.
J7340 Carbidopa/Levodopa Part B MAC if incident to a physician’s service
or used in an implanted infusion pump. If
other, DME MAC.
J7500 - J7599 Immunosuppressive Drugs Part B MAC if incident to a physician’s service
or used in an implanted infusion pump. If
other, DME MAC.
J7604 - J7699 Inhalation Solutions Part B MAC if incident to a physician’s
 service. If other, DME MAC.
J7799-J7999 NOC Drugs, Other than Inhalation Part B MAC if incident to a physician’s service
Drugs or used in an implanted infusion pump. If
other, DME MAC.
J8498 Anti-emetic Drug DME MAC
J8499 Prescription Drug, Oral, Non Part B MAC if incident to a physician’s
Chemotherapeutic service. If other, DME MAC.
J8501 - J8999 Oral Anti-Cancer Drugs DME MAC
J9000 - J9999 Chemotherapy Drugs Part B MAC if incident to a physician’s service
or used in an implanted infusion pump. If
other, DME MAC.
K0001 - K0108 Wheelchairs DME MAC
K0195 Elevating Leg Rests DME MAC
K0455 Infusion Pump used for Uninterrupted DME MAC
Administration of Epoprostenal
K0462 Loaner Equipment DME MAC
K0552 - K0605 External Infusion Pump Supplies & DME MAC
Continuous Glucose Monitor
K0606 - K0609 Defibrillator Accessories DME MAC
K0669 Wheelchair Cushion DME MAC
K0672 Soft Interface for Orthosis DME MAC
K0730 Inhalation Drug Delivery System DME MAC
K0733 Power Wheelchair Accessory DME MAC
K0738 Oxygen Equipment DME MAC
K0739 Repair or Nonroutine Service for DME Part B MAC if implanted DME. If other, DME
MAC.
K0740 Repair or Nonroutine Service for DME MAC
Oxygen Equipment

K0743 - K0746 Suction Pump and Dressings DME MAC

K0800 - K0899 Power Mobility Devices DME MAC
K0900 Custom DME, other than Wheelchair DME MAC
K1001-K1004 Devices DME MAC
K1005 Device Accessory DME MAC
K1006-K1012 Devices DME MAC when the supplier considers the
item DMEPOS. Part B MAC if the supplier
considers the item something other than
DMEPOS (e.g., supplies furnished incident to
the professional service of a physician).
K1013-K1020 Devices DME MAC when the supplier considers the
item DMEPOS. Part B MAC if the supplier
considers the item something other than
DMEPOS (e.g., supplies furnished incident to
the professional service of a physician).
K1021 Accessory DME MAC
K1022-K1027 Devices DME MAC when the supplier considers the
item DMEPOS. Part B MAC if the supplier
considers the item something other than
DMEPOS (e.g., supplies furnished incident to
the professional service of a physician).
L0112 - L4631 Orthotics & Devices DME MAC
L5000 - L5999 Lower Limb Prosthetics DME MAC
L6000 - L7499 Upper Limb Prosthetics DME MAC
L7510 - L7520 Repair of Prosthetic Device Part B MAC if repair of implanted prosthetic
device. If other, DME MAC.
L7600 - L8485 Prosthetics DME MAC
L8499 Unlisted Procedure for Miscellaneous Part B MAC if implanted prosthetic device. If
Prosthetic Services other, DME MAC.
L8500 - L8501 Artificial Larynx; Tracheostomy DME MAC
Speaking Valve
L8505 Artificial Larynx Accessory DME MAC
L8507 Voice Prosthesis, Patient Inserted DME MAC
L8509 Voice Prosthesis, Inserted by a Licensed Part B MAC for dates of service on or after
Health Care Provider 10/01/2010. DME MAC for dates of service
prior to 10/01/2010
L8510 Voice Prosthesis DME MAC
L8511 - L8515 Voice Prosthesis Part B MAC if used with tracheoesophageal
voice prostheses inserted by a licensed health
care provider. If other, DME MAC
L8701 - L8702 Assist Device DME MAC
L9900 Miscellaneous Orthotic or Prosthetic Part B MAC if used with implanted prosthetic
Component or Accessory device. If other, DME MAC.
Q0144 Azithromycin Dihydrate Part B MAC if incident to a physician’s
service. If other, DME MAC.
Q0161 - Q0181 Anti-emetic DME MAC
Q2049-Q2050 Doxorubicin Part B MAC if incident to a physician’s service
or used in an implanted infusion pump. If
other, DME MAC.
Q2052 IVIG Demonstration DME MAC
Q4074 Inhalation Drug Part B MAC if incident to a physician’s
service. If other, DME MAC.
Q9991 - Q9992 Injection Part B MAC if incident to a physician’s service
or used in an implanted infusion pump. If
other, DME MAC.
V2020 - V2025 Frames DME MAC
V2100 - V2513 Lenses DME MAC
V2520 - V2523 Hydrophilic Contact Lenses Part B MAC if incident to a physician’s
service. If other, DME MAC.
V2524 Device DME MAC when the supplier considers the
item DMEPOS. Part B MAC if the supplier
considers the item something other than
 DMEPOS (e.g., supplies furnished incident to
the professional service of a physician).
V2530 - V2531 Contact Lenses, Scleral DME MAC
V2599 Contact Lens, Other Type Part B MAC if incident to a physician’s
service. If other, DME MAC.
V2600 - V2615 Low Vision Aids DME MAC
V2623 - V2629 Prosthetic Eyes DME MAC
V2700 - V2780 Miscellaneous Vision Service DME MAC
V2781 Progressive Lens DME MAC
V2782 - V2784 Lenses DME MAC
V2786 Lens DME MAC
V2797 Vision Supply DME MAC
V2799 Miscellaneous Vision Service Part B MAC if supply for an implanted
prosthetic device. If other, DME MAC
V5336 Repair/Modification of Augmentative DME MAC
Communicative System or Device
 APPENDIX B
CHAPTER I
GENERAL CORRECT CODING POLICIES
NATIONAL CORRECT CODING INITIATIVE POLICY
MANUAL FOR MEDICAID SERVICES
Revised January 1, 2022
Current Procedural Terminology (CPT) codes, descriptions and other data only are copyright 2021 American Medical
Association. All rights reserved.
CPT® is a registered trademark of the American Medical Association.
Applicable FARS\DFARS Restrictions Apply to Government Use.
Fee schedules, relative value units, conversion, prospective payment systems factors and/or related components are not
assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or
indirectly practice medicine or dispense medical services. The AMA assumes no liability for the data contained or not
contained herein.

Chapter I
Revision Date 1/1/2022
GENERAL CORRECT CODING POLICIES
A. Introduction
Healthcare providers/suppliers use Healthcare Common Procedure Coding System/Current
Procedural Terminology (HCPCS/CPT) codes to report medical services performed on
patients to Medicare Administrative Contractors (MACs). Healthcare Common Procedure
Coding System (HCPCS) consists of Level I CPT (Current Procedural Terminology) codes
and Level II codes. CPT codes are defined in the American Medical Association’s (AMA’s)
“CPT Manual,” which is updated and published annually. HCPCS Level II codes are defined
by the Centers for Medicare & Medicaid Services (CMS) and are updated throughout the
year as necessary. Changes in CPT codes are approved by the AMA CPT Editorial Panel,
which meets 3 times per year.

CPT and HCPCS Level II codes define medical and surgical procedures performed on
patients. Some procedure codes are very specific in defining a single service (e.g., CPT code
93000 (electrocardiogram)), while other codes define procedures consisting of many services
(e.g., CPT code 58263 (vaginal hysterectomy, for uterus 250 g or less; with removal of
tube(s) and ovary(s) and repair of enterocele)). Because many procedures can be performed
via different approaches, different methods, or in combination with other procedures, there
are often multiple HCPCS/CPT codes defining similar or related procedures.

CPT and HCPCS Level II code descriptors usually do not define all services included in a
procedure. There are often services inherent in a procedure or group of procedures. For
example, anesthesia services include certain preparation and monitoring services.

The CMS developed the National Correct Coding Initiative (NCCI) program to prevent
inappropriate payment of services that should not be reported together. Prior to April 1, 2012,
NCCI Procedure-to-Procedure (PTP) edits were placed into either the “Column One/Column
Two Correct Coding Edit Table” or the “Mutually Exclusive Edit Table.” However, on April
1, 2012, the edits in the “Mutually Exclusive Edit Table” were moved to the “Column
One/Column Two Correct Coding Edit Table” so that all NCCI PTP edits are currently
contained in this single table. Combining the 2 tables simplifies researching NCCI PTP edits
and online use of the NCCI tables.

Each edit table contains edits which are pairs of HCPCS/CPT codes that in general should
not be reported together. Each edit has a Column One and Column Two HCPCS/CPT code. If
a provider/supplier reports the 2 codes of an edit pair, the Column Two code is denied, and
the Column One code is eligible for payment. However, if it is clinically appropriate to use
an NCCI PTP-associated modifier, both the Column One and Column Two codes are eligible
for payment. (NCCI PTP-associated modifiers and their appropriate use are discussed
elsewhere in this chapter.)

When the NCCI program was first established and during its early years, the “Column
One/Column Two Correct Coding Edit Table” was termed the “Comprehensive/Component
Edit Table.” This latter terminology was a misnomer. Although the Column Two code is
often a component of a more comprehensive Column One code, this relationship is not true
for many edits. In the latter type of edit, the code pair edit simply represents 2 codes that
should not be reported together. For example, a provider/supplier shall not report a vaginal
hysterectomy code and total abdominal hysterectomy code together.

In this chapter, Sections B–Q address various issues relating to NCCI PTP edits.

Medically Unlikely Edits (MUEs) prevent payment for a potentially inappropriate

number/quantity of the same service on a single day. An MUE for a HCPCS/CPT code is the
maximum number of units of service (UOS) reportable under most circumstances by the
same provider/supplier for the same beneficiary on the same date of service. The ideal MUE
value for a HCPCS/CPT code is one that allows the vast majority of appropriately coded
claims to pass the MUE. For more information concerning MUEs, see Section V of this
chapter.

In this Manual, many policies are described using the term “physician.” Unless otherwise
indicated, the use of this term does not restrict the application of policies to physicians only.
Rather, the policies apply to all practitioners, hospitals, providers, or suppliers eligible to bill
the relevant HCPCS/CPT codes pursuant to applicable portions of the Social Security Act
(SSA) of 1965, the Code of Federal Regulations (CFR), and Medicare rules. In some sections
of this Manual, the term “physician” would not include some of these entities because
specific rules do not apply to them. For example, Anesthesia Rules [e.g., CMS “Internet-only
Manual (IOM),” Publication 100-04 (“Medicare Claims Processing Manual”), Chapter 12
(Physician/Nonphysician Practitioners), Section 50 (Payment for Anesthesiology Services)]
and Global Surgery Rules [e.g., CMS “Internet-only Manual (IOM),” Publication 100-04
(“Medicare Claims Processing Manual”), Chapter 12 (Physician/Nonphysician Practitioners),
Section 40 (Surgeons and Global Surgery)] do not apply to hospitals.

Providers/suppliers reporting services under Medicare’s hospital Outpatient Prospective

Payment System (OPPS) shall report all services in accordance with appropriate Medicare
“IOM” instructions.

Providers/suppliers must report services correctly. This manual discusses general coding
principles in Chapter I, and principles more relevant to other specific groups of HCPCS/CPT
codes in the other chapters. There are certain types of improper coding that
providers/suppliers must avoid.

Procedures shall be reported with the most comprehensive CPT code that describes the
services performed. Providers/suppliers must not unbundle the services described by a
HCPCS/CPT code. Some examples follow:

• A provider/supplier shall not report multiple HCPCS/CPT codes when a single

comprehensive HCPCS/CPT code describes these services. For example, if a physician
performs a vaginal hysterectomy on a uterus weighing less than 250 grams with bilateral
salpingo-oophorectomy, the provider/supplier shall report CPT code 58262 (Vaginal
hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s)). The
provider/supplier shall not report CPT code 58260 (Vaginal hysterectomy, for uterus 250 g
or less;) plus CPT code 58720 (Salpingo-oophorectomy, complete or partial, unilateral, or
bilateral (separate procedure)).
• A physician shall not fragment a procedure into component parts. For example, if a
physician performs an anal endoscopy with biopsy, the provider/supplier shall report CPT
code 46606 (Anoscopy; with biopsy, single or multiple). It is improper to unbundle this
procedure and report CPT code 46600 (Anoscopy; diagnostic…) plus CPT code 45100
(Biopsy of anorectal wall, anal approach…). The latter code is not intended to be used with
an endoscopic procedure code.
• A provider/supplier shall not unbundle a bilateral procedure code into 2 unilateral
procedure codes. For example, if a physician performs bilateral mammography, the
provider/supplier shall report CPT code 77066 (Diagnostic mammography…bilateral). The
provider/supplier shall not report CPT code 77065 (Diagnostic mammography…unilateral)
with 2 UOS or 77065 LT plus 77065 RT.
• A provider/supplier shall not unbundle services that are integral to a more comprehensive
procedure. For example, surgical access is integral to a surgical procedure. A
provider/supplier shall not report CPT code 49000 (Exploratory laparotomy…) when
performing an open abdominal procedure such as a total abdominal colectomy (e.g., CPT
code 44150).
• Providers/suppliers shall only report a biopsy separately when pathologic examination
results in a decision to immediately proceed with a more extensive procedure (e.g.,
excision, destruction, removal) on the same lesion; or when performed on a separate
lesion.
• Providers/suppliers shall not report a biopsy separately when it is to assess resection
margins or to verify resectability; or when performed and submitted for pathologic
evaluation completed after performing the more extensive procedure.

Providers/suppliers must avoid downcoding. If a HCPCS/CPT code exists that describes the
services performed, the providers/ suppliers must report this code rather than report a less
comprehensive code with other codes describing the services not included in the less
comprehensive code. For example, if a physician performs a unilateral partial mastectomy
with axillary lymphadenectomy, the provider/supplier shall report CPT code 19302
(Mastectomy, partial…; with axillary lymphadenectomy). A provider/supplier shall not
report CPT code 19301 (Mastectomy, partial…) plus CPT code 38745 (Axillary
lymphadenectomy; complete).

Providers/suppliers must avoid upcoding. A HCPCS/CPT code may be reported only if all
services described by that code have been performed. For example, if a physician performs a
superficial axillary lymphadenectomy (CPT code 38740), the provider/supplier shall not
report CPT code 38745 (Axillary lymphadenectomy; complete).

Providers/suppliers must report UOS correctly. Each HCPCS/CPT code has a defined unit of
service for reporting purposes. A provider/supplier shall not report UOS for a HCPCS/CPT
code using a criterion that differs from the code’s defined unit of service. For example, some
therapy codes are reported in fifteen-minute increments (e.g., CPT codes 97110-97124).
Others are reported per session (e.g., CPT codes 92507, 92508). A provider/supplier shall not
report a per session code using fifteen-minute increments. CPT code 92507 or 92508 should
be reported with one unit of service on a single date of service.

The MUE values and NCCI PTP edits are based on services provided by the same physician
to the same beneficiary on the same date of service. Physicians shall not inconvenience
beneficiaries nor increase risks to beneficiaries by performing services on different dates of
service to avoid MUE or NCCI PTP edits.

In 2010, the “CPT Manual” modified the numbering of codes so that the sequence of codes
as they appear in the “CPT Manual” does not necessarily correspond to a sequential
numbering of codes. In the “National Correct Coding Initiative Policy Manual for Medicare
Services”, use of a numerical range of codes reflects all codes that numerically fall within the
range regardless of their sequential order in the “CPT Manual”.

This chapter addresses general coding principles, issues, and policies. Many of these
principles, issues, and policies are addressed further in subsequent chapters dealing with
specific groups of HCPCS/CPT codes. In this chapter, examples are often used to clarify
principles, issues, or policies. The examples do not represent the only codes to which the
principles, issues, or policies apply.

B. Coding Based on Standards of Medical/Surgical Practice

Most HCPCS/CPT code defined procedures include services that are integral to them. Some
of these integral services have specific CPT codes for reporting the service when not
performed as an integral part of another procedure. (For example, CPT code 36000
(Introduction of needle or intracatheter, vein) is integral to all nuclear medicine procedures
requiring injection of a radiopharmaceutical into a vein. CPT code 36000 is not separately
reportable with these types of nuclear medicine procedures. However, CPT code 36000 may
be reported alone if the only service provided is the introduction of a needle into a vein.
Other integral services do not have specific CPT codes. (For example, wound irrigation is
integral to the treatment of all wounds and does not have a HCPCS/CPT code.) Services
integral to HCPCS/CPT code defined procedures are included in those procedures based
upon the standards of medical/surgical practice. It is inappropriate to separately report
services that are integral to another procedure with that procedure.

Many NCCI PTP edits are based upon the standards of medical/surgical practice. Services
that are integral to another service are component parts of the more comprehensive service.
When integral component services have their own HCPCS/CPT codes, NCCI PTP edits place
the comprehensive service in Column One and the component service in Column Two. Since
a component service integral to a comprehensive service is not separately reportable, the
Column Two code is not separately reportable with the Column One code.

Some services are integral to large numbers of procedures. Other services are integral to a
more limited number of procedures. Examples of services integral to a large number of
procedures include:
• Cleansing, shaving and prepping of skin
• Draping and positioning of patient
• Insertion of intravenous access for medication administration;
• Insertion of urinary catheter
• Sedative administration by the physician performing a procedure (see Chapter II,
Anesthesia Services)
• Local, topical or regional anesthesia administered by the physician performing the
procedure
• Surgical approach including identification of anatomical landmarks, incision, evaluation of
the surgical field, debridement of traumatized tissue, lysis of adhesions, and isolation of
structures limiting access to the surgical field such as bone, blood vessels, nerve, and
muscles including stimulation for identification or monitoring - Surgical cultures
• Wound irrigation
• Insertion and removal of drains, suction devices, and pumps into same site
• Surgical closure and dressings
• Application, management, and removal of postoperative dressings and analgesic devices
(peri-incisional)
• Application of TENS unit
• Institution of Patient Controlled Anesthesia
• Preoperative, intraoperative and postoperative documentation, including photographs,
drawings, dictation, or transcription as necessary to document the services provided
• Imaging and/or ultrasound guidance
• Surgical supplies, except for specific situations where CMS policy permits separate
payment.

Although other chapters in this Manual further address issues related to the standards of
medical/surgical practice for the procedures covered by that chapter, it is not possible to
discuss all NCCI PTP edits based upon the principle of the standards of medical/surgical
practice due to space limitations. However, there are several general principles that can be
applied to the edits, as follows:

1. The component service is an accepted standard of care when performing the

comprehensive service.
2. The component service is usually necessary to complete the comprehensive service.
3. The component service is not a separately distinguishable procedure when performed with
the comprehensive service.

Specific examples of services that are not separately reportable because they are components
of more comprehensive services follow:

Medical Examples
1. Because interpretation of cardiac rhythm is an integral component of the interpretation of
an electrocardiogram, a rhythm strip is not separately reportable.
2. Because determination of ankle/brachial indices requires both upper and lower extremity
Doppler studies, an upper extremity Doppler study is not separately reportable.
3. Because a cardiac stress test includes multiple electrocardiograms, an electrocardiogram is
not separately reportable.

Surgical Examples

1. Because a myringotomy requires access to the tympanic membrane through the external
auditory canal, removal of impacted cerumen from the external auditory canal is not
separately reportable.
2. A “scout” bronchoscopy to assess the surgical field, anatomic landmarks, extent of
disease, etc., is not separately reportable with an open pulmonary procedure such as a
pulmonary lobectomy. By contrast, an initial diagnostic bronchoscopy is separately
reportable. If the diagnostic bronchoscopy is performed at the same patient encounter as
the open pulmonary procedure and does not duplicate an earlier diagnostic bronchoscopy
by the same or another physician, the diagnostic bronchoscopy may be reported with
modifier 58 appended to the open pulmonary procedure code to indicate a staged
procedure. A cursory examination of the upper airway during a bronchoscopy with the
bronchoscope shall not be reported separately as a laryngoscopy. However, separate
endoscopies of anatomically distinct areas with different endoscopes may be reported
separately (e.g., thoracoscopy and mediastinoscopy).
3. If an endoscopic procedure is performed at the same patient encounter as a non-
endoscopic procedure to ensure no intraoperative injury occurred or verify the procedure
was performed correctly, the endoscopic procedure is not separately reportable with the
non-endoscopic procedure.
4. Because a colectomy requires exposure of the colon, the laparotomy and adhesiolysis to
expose the colon are not separately reportable.

Medical/Surgical Package
Most medical and surgical procedures include pre-procedure, intra-procedure, and post-
procedure work. When multiple procedures are performed at the same patient encounter,
there is often overlap of the pre-procedure and post-procedure work. Payment methodologies
for surgical procedures account for the overlap of the pre-procedure and post-procedure
work.

The component elements of the pre-procedure and post-procedure work for each procedure
are included component services of that procedure as a standard of medical/surgical practice.
Some general guidelines follow:
 1. Many invasive procedures require vascular and/or airway access. The work associated
with obtaining the required access is included in the pre-procedure or intra-procedure
work. The work associated with returning a patient to the appropriate post-procedure
state is included in the post-procedure work.

Airway access is necessary for general anesthesia and is not separately reportable. There is
no CPT code for elective endotracheal intubation. CPT code 31500 describes an emergency
endotracheal intubation and shall not be reported for elective endotracheal intubation.
Visualization of the airway is a component part of an endotracheal intubation, and CPT codes
describing procedures that visualize the airway (e.g., nasal endoscopy, laryngoscopy,
bronchoscopy) shall not be reported with an endotracheal intubation. These CPT codes
describe diagnostic and therapeutic endoscopies, and it is a misuse of these codes to report
visualization of the airway for endotracheal intubation.

Intravenous access (e.g., CPT codes 36000, 36400, 36410) is not separately reportable when
performed with many types of procedures (e.g., surgical procedures, anesthesia procedures,
radiological procedures requiring intravenous contrast, nuclear medicine procedures
requiring intravenous radiopharmaceutical).

After vascular access is achieved, the access must be maintained by a slow infusion (e.g.,
saline) or injection of heparin or saline into a “lock.” Since these services are necessary for
maintenance of the vascular access, they are not separately reportable with the vascular
access CPT codes or procedures requiring vascular access as a standard of medical/surgical
practice. CPT codes 37211-37214 (Transcatheter therapy with infusion for thrombolysis)
shall not be reported for use of an anticoagulant to maintain vascular access.

The global surgical package includes the administration of fluids and drugs during the
operative procedure. CPT codes 96360-96377 shall not be reported separately for that
operative procedure. Under OPPS, the administration of fluids and drugs during or for an
operative procedure are included services and are not separately reportable (e.g., CPT codes
96360-96377).

When a procedure requires more invasive vascular access services (e.g., central venous
access, pulmonary artery access), the more invasive vascular service is separately reportable
if it is not typical of the procedure and the work of the more invasive vascular service has not
been included in the valuation of the procedure.

Insertion of a central venous access device (e.g., central venous catheter, pulmonary artery
catheter) requires passage of a catheter through central venous vessels and, in the case of a
pulmonary artery catheter, through the right atrium and ventricle. These services often
require the use of fluoroscopic guidance. Separate reporting of CPT codes for right heart
catheterization, selective venous catheterization, or pulmonary artery catheterization is not
appropriate when reporting a CPT code for insertion of a central venous access device. Since
CPT code 77001 describes fluoroscopic guidance for central venous access device
procedures, CPT codes for more general fluoroscopy (e.g., 76000, 77002) shall not be
reported separately. (CPT code 76001 was deleted January 1, 2019.)

2. Medicare Anesthesia Rules prevent separate payment for anesthesia services by the same
physician performing a surgical or medical procedure. The physician performing a
surgical or medical procedure shall not report CPT codes 96360-96377 for the
administration of anesthetic agents during the procedure. If it is medically reasonable
and necessary that a separate provider/supplier (anesthesia practitioner) perform
anesthesia services (e.g., monitored anesthesia care) for a surgical or medical procedure,
a separate anesthesia service may be reported by the second provider/supplier.

Under the OPPS, anesthesia for a surgical procedure is an included service and is not
separately reportable. For example, a provider/supplier shall not report CPT codes 96360-
96377 for anesthesia services.

When anesthesia services are not separately reportable, providers/ suppliers shall not
unbundle components of anesthesia and report them in lieu of an anesthesia code.

3. If an endoscopic procedure is performed at the same patient encounter as a non-

endoscopic procedure to ensure that no intraoperative injury occurred or to verify that
the procedure was performed correctly, the endoscopic procedure is not separately
reportable with the non-endoscopic procedure.
4. Many procedures require cardiopulmonary monitoring, either by the physician
performing the procedure or an anesthesia practitioner. Since these services are integral
to the procedure, they are not separately reportable. Examples of these services include
cardiac monitoring, pulse oximetry, and ventilation management (e.g., 93000-93010,
93040-93042, 94760, 94761).
5. See Section A, Introduction.
6. Exposure and exploration of the surgical field is integral to an operative procedure and is
not separately reportable. For example, an exploratory laparotomy (CPT code 49000) is
not separately reportable with an intra-abdominal procedure. If exploration of the
surgical field results in additional procedures other than the primary procedure, the
additional procedures may generally be reported separately. However, a procedure
designated by the CPT code descriptor as a “separate procedure” is not separately
reportable if performed in a region anatomically related to the other procedure(s) through
the same skin incision, orifice, or surgical approach.
7. If a definitive surgical procedure requires access through diseased tissue (e.g., necrotic
skin, abscess, hematoma, seroma), a separate service for this access (e.g., debridement,
incision, and drainage) is not separately reportable. Types of procedures to which this
 principle applies include, but are not limited to, -ectomy, -otomy, excision, resection, -
plasty, insertion, revision, replacement, relocation, removal, or closure. For example,
debridement of skin and subcutaneous tissue at the site of an abdominal incision made to
perform an intra-abdominal procedure is not separately reportable. (See Chapter IV,
Section I (General Policy Statements), Subsection 11 for guidance on reporting
debridement with open fractures and dislocations.)
8. If removal, destruction, or other form of elimination of a lesion requires coincidental
elimination of other pathology, only the primary procedure may be reported. For
example, if an area of pilonidal disease contains an abscess, incision, and drainage of the
abscess during the procedure to excise the area of pilonidal disease is not separately
reportable.
9. An excision and removal (-ectomy) includes the incision and opening (-otomy) of the
organ. A HCPCS/CPT code for an –otomy procedure shall not be reported with an –
ectomy code for the same organ.
10. Multiple approaches to the same procedure are mutually exclusive of one another and
shall not be reported separately. For example, both a vaginal hysterectomy and
abdominal hysterectomy shall not be reported separately.
11. If a procedure using one approach fails and is converted to a procedure using a different
approach, only the completed procedure may be reported. For example, if a laparoscopic
hysterectomy is converted to an open hysterectomy, only the open hysterectomy
procedure code may be reported.
12. If a laparoscopic procedure fails and is converted to an open procedure, the physician
shall not report a diagnostic laparoscopy in lieu of the failed laparoscopic procedure. For
example, if a laparoscopic cholecystectomy is converted to an open cholecystectomy, the
physician shall not report the failed laparoscopic cholecystectomy nor a diagnostic
laparoscopy.
13. If a diagnostic endoscopy is the basis for and precedes an open procedure, the diagnostic
endoscopy may be reported with modifier 58 appended to the open procedure code.
However, the medical record must document the medical reasonableness and necessity
for the diagnostic endoscopy. A scout endoscopy to assess anatomic landmarks and
extent of disease is not separately reportable with an open procedure. When an
endoscopic procedure fails and is converted to another surgical procedure, only the
completed surgical procedure may be reported. The endoscopic procedure is not
separately reportable with the completed surgical procedure.
14. Treatment of complications of primary surgical procedures is separately reportable with
some limitations. The global surgical package for an operative procedure includes all
intra-operative services that are normally a usual and necessary part of the procedure.
Additionally, the global surgical package includes all medical and surgical services
required of the surgeon during the postoperative period of the surgery to treat
complications that do not require return to the operating room. Thus, treatment of a
complication of a primary surgical procedure is not separately reportable:
 (1) if it represents usual and necessary care in the operating room during the procedure;
or
(2) if it occurs postoperatively and does not require return to the operating room. For
example, control of hemorrhage is a usual and necessary component of a surgical
procedure in the operating room and is not separately reportable. Control of
postoperative hemorrhage is also not separately reportable unless the patient must be
returned to the operating room for treatment. In the latter case, the control of
hemorrhage may be separately reportable with modifier 78.

D. Evaluation & Management (E&M) Services

Medicare Global Surgery Rules define the rules for reporting Evaluation & Management
(E&M) services with procedures covered by these rules. This section summarizes some of
the rules.

All procedures on the Medicare Physician Fee Schedule are assigned a global period of 000,
010, 090, XXX, YYY, ZZZ, or MMM. The global concept does not apply to XXX
procedures. The global period for YYY procedures is defined by the MAC. All procedures
with a global period of ZZZ are related to another procedure, and the applicable global period
for the ZZZ code is determined by the related procedure. Procedures with a global period of
MMM are maternity procedures.

Since NCCI PTP edits are applied to same-day services by the same provider to the same
beneficiary, certain Global Surgery Rules are applicable to the NCCI program. An E&M
service is separately reportable on the same date of service as a procedure with a global
period of 000, 010, or 090 under limited circumstances.

If a procedure has a global period of 090 days, it is defined as a major surgical procedure. If
an E&M service is performed on the same date of service as a major surgical procedure for
the purpose of deciding whether to perform this surgical procedure, the E&M service is
separately reportable with modifier 57. Other preoperative E&M services on the same date of
service as a major surgical procedure are included in the global payment for the procedure
and are not separately reportable. NCCI does not contain edits based on this rule because
MACs have separate edits.

If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical
procedure. In general, E&M services performed on the same date of service as a minor
surgical procedure are included in the payment for the procedure. The decision to perform a
minor surgical procedure is included in the payment for the minor surgical procedure and
shall not be reported separately as an E&M service. However, a significant and separately
identifiable E&M service unrelated to the decision to perform the minor surgical procedure is
separately reportable with modifier 25. The E&M service and minor surgical procedure do
not require different diagnoses. If a minor surgical procedure is performed on a new patient,
the same rules for reporting E&M services apply. The fact that the patient is “new” to the
provider/supplier is not sufficient alone to justify reporting an E&M service on the same date
of service as a minor surgical procedure. NCCI contains many, but not all, possible edits
based on these principles.

For major and minor surgical procedures, postoperative E&M services related to recovery
from the surgical procedure during the postoperative period are included in the global
surgical package as are E&M services related to complications of the surgery. Postoperative
visits unrelated to the diagnosis for which the surgical procedure was performed, unless
related to a complication of surgery, may be reported separately on the same day as a surgical
procedure with modifier 24 (“Unrelated Evaluation and Management Service by the Same
Physician or Other Qualified Health Care Professional During a Postoperative Period”).

Procedures with a global surgery indicator of “XXX” are not covered by these rules. Many of
these “XXX” procedures are performed by physicians and have inherent pre-procedure,
intraprocedure, and post-procedure work usually performed each time the procedure is
completed. This work shall not be reported as a separate E&M code. Other “XXX”
procedures are not usually performed by a physician and have no physician work relative
value units associated with them. A physician shall not report a separate E&M code with
these procedures for the supervision of others performing the procedure or for the
interpretation of the procedure. With most “XXX” procedures, the physician may, however,
perform a significant and separately identifiable E&M service on the same date of service
which may be reported by appending modifier 25 to the E&M code. This E&M service may
be related to the same diagnosis necessitating performance of the “XXX” procedure but
cannot include any work inherent in the “XXX” procedure, supervision of others performing
the “XXX” procedure, or time for interpreting the result of the “XXX” procedure. Appending
modifier 25 to a significant, separately identifiable E&M service when performed on the
same date of service as an “XXX” procedure is correct coding.

E. Modifiers and Modifier Indicators

1. The AMA “CPT Manual” and the CMS define modifiers that may be appended to
HCPCS/CPT codes to provide additional information about the services rendered.
Modifiers consist of 2 alphanumeric characters.

Modifiers may be appended to HCPCS/CPT codes only if the clinical circumstances justify
the use of the modifier. A modifier shall not be appended to a HCPCS/CPT code solely to
bypass an NCCI PTP edit if the clinical circumstances do not justify its use. If the Medicare
program imposes restrictions on the use of a modifier, the modifier may only be used to
bypass an NCCI PTP edit if the Medicare restrictions are fulfilled. Modifiers that may be
used under appropriate clinical circumstances to bypass an NCCI PTP edit include:
Anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI

Global surgery modifiers: 24, 25, 57, 58, 78, 79

Other modifiers: 27, 59, 91, XE, XS, XP, XU

Modifiers 76 (“Repeat Procedure or Service by Same Physician”) and 77 (“Repeat Procedure

by Another Physician”) are not NCCI PTP-associated modifiers. Use of either of these
modifiers does not bypass an NCCI PTP edit.

Each NCCI PTP edit has an assigned modifier indicator. A modifier indicator of “0” indicates
that NCCI PTP-associated modifiers cannot be used to bypass the edit. A modifier indicator
of “1” indicates that NCCI PTP-associated modifiers may be used to bypass an edit under
appropriate circumstances. A modifier indicator of “9” indicates that the edit has been
deleted, and the modifier indicator is not relevant.

It is very important that NCCI PTP-associated modifiers only be used when appropriate. In
general, these circumstances relate to separate patient encounters, separate anatomic sites, or
separate specimens. (See subsequent discussion of modifiers in this section.) Most edits
involving paired organs or structures (e.g., eyes, ears, extremities, lungs, kidneys) have NCCI
PTP modifier indicators of “1” because the 2 codes of the code pair edit may be reported if
performed on the contralateral organs or structures. Most of these code pairs should not be
reported with NCCI PTP-associated modifiers when performed on the ipsilateral organ or
structure unless there is a specific coding rationale to bypass the edit. The existence of the
NCCI PTP edit indicates that the 2 codes generally cannot be reported together unless the 2
corresponding procedures are performed at 2 separate patient encounters or 2 separate
anatomic locations. However, if the 2 corresponding procedures are performed at the same
patient encounter and in contiguous structures in the same organ or anatomic region, NCCI
PTP-associated modifiers generally should not be used.

The appropriate use of most of these modifiers is straightforward. However, further

explanation is provided regarding modifiers 25, 58, and 59. Although modifier 22 is not a
modifier that bypasses an NCCI PTP edit, its use is occasionally relevant to an NCCI PTP
edit and is discussed below.

a) Modifier 22: Modifier 22 is defined by the “CPT Manual” as “Increased Procedural

Services.” This modifier shall not be reported unless the service(s) performed is (are)
substantially more extensive than the usual service(s) included in the procedure
described by the HCPCS/CPT code reported.

Occasionally, a provider may perform 2 procedures that should not be reported together
based on an NCCI PTP edit. If the edit allows use of NCCI PTP-associated modifiers to
bypass it and the clinical circumstances justify use of one of these modifiers, both services
may be reported with the NCCI PTP-associated modifier. However, if the NCCI PTP edit
does not allow use of NCCI PTP-associated modifiers to bypass it and the procedure
qualifies as an unusual procedural service, the physician may report the Column One
HCPCS/CPT code of the NCCI PTP edit with modifier 22. The MAC may then evaluate the
unusual procedural service to determine whether additional payment is justified.

For example, CMS limits payment for CPT code 69990 (Microsurgical techniques, requiring
use of operating microscope…) to procedures listed in the “IOM” (“Claims Processing
Manual”, Publication 100-04, 12-§20.4.5). If a physician reports CPT code 69990 with 2
other CPT codes and 1 of the codes is not on this list, an NCCI PTP edit with the code not on
the list will prevent payment for CPT code 69990. Claims processing systems do not
determine which procedure is linked with CPT code 69990. In situations such as this, the
physician may submit their claim to the local MAC for readjudication appending modifier 22
to the CPT code. Although MAC cannot override an NCCI PTP edit that does not allow use
of NCCI PTP-associated modifiers, the MAC has discretion to adjust payment to include use
of the operating microscope based on modifier 22.

b) Modifier 25: The “CPT Manual” defines modifier 25 as a “Significant, Separately

Identifiable Evaluation and Management Service by the Same Physician or Other
Qualified Health Care Professional on the Same Day of the Procedure or Other
Service.” Modifier 25 may be appended to an evaluation and management (E&M) CPT
code to indicate that the E&M service is significant and separately identifiable from
other services reported on the same date of service. The E&M service may be related
to the same or different diagnosis as the other procedure(s).

Modifier 25 may be appended to E&M services reported with minor surgical procedures
(with global periods of 000 or 010 days) or procedures not covered by Global Surgery Rules
(with a global indicator of XXX). Since minor surgical procedures and XXX procedures
include preprocedure, intra-procedure, and post-procedure work inherent in the procedure,
the provider/supplier shall not report an E&M service for this work. Furthermore, Medicare
Global Surgery Rules prevent the reporting of a separate E&M service for the work
associated with the decision to perform a minor surgical procedure regardless of whether the
patient is a new or established patient.

c) Modifier 58: Modifier 58 is defined by the “CPT Manual” as a “Staged or Related

Procedure or Service by the Same Physician or Other Qualified Health Care
Professional During the Postoperative Period.” It may be used to indicate that a
procedure was followed by a second procedure during the post-operative period of the
first procedure. This situation may occur because the second procedure was planned
prospectively, was more extensive than the first procedure, or was therapy after a
 diagnostic surgical service. Use of modifier 58 will bypass NCCI PTP edits that allow
use of NCCI PTP-associated modifiers.

If a diagnostic endoscopic procedure results in the decision to perform an open procedure,

both procedures may be reported with modifier 58 appended to the HCPCS/CPT code for the
open procedure. However, if the endoscopic procedure preceding an open procedure is a
“scout” procedure to assess anatomic landmarks and/or extent of disease, it is not separately
reportable.

Diagnostic endoscopy is never separately reportable with another endoscopic procedure of

the same organ(s) or anatomic region when performed at the same patient encounter.
Similarly, diagnostic laparoscopy is never separately reportable with a surgical laparoscopic
procedure of the same body cavity when performed at the same patient encounter.

If a planned laparoscopic procedure fails and is converted to an open procedure, only the
open procedure may be reported. The failed laparoscopic procedure is not separately
reportable. The NCCI program contains many, but not all, edits bundling laparoscopic
procedures into open procedures. Since the number of possible code combinations bundling a
laparoscopic procedure into an open procedure is much greater than the number of such edits
in the NCCI program, the principle stated in this paragraph is applicable regardless of
whether the selected code pair combination is included in the NCCI tables. A
provider/supplier shall not select laparoscopic and open HCPCS/CPT codes to report because
the combination is not included in the NCCI tables.

d) Modifier 59: Modifier 59 is an important NCCI PTP-associated modifier that is often

used incorrectly. For the NCCI program, its primary purpose is to indicate that 2 or
more procedures are performed at different anatomic sites or different patient
encounters. One function of NCCI PTP edits is to prevent payment for codes that
report overlapping services, except in those instances where the services are “separate
and distinct.” Modifier 59 shall only be used if no other modifier more appropriately
describes the relationships of the 2 or more procedure codes (see Section E for
modifiers -X{EPSU}). The “CPT Manual” defines modifier 59 as follows:

Modifier 59: Distinct Procedural Service: Under certain circumstances, it may be

necessary to indicate that a procedure or service was distinct or independent from other
non-E/M services performed on the same day. Modifier 59 is used to identify
procedures/services, other than E/M services, that are not normally reported together,
but are appropriate under the circumstances. Documentation must support a different
session, different procedure or surgery, different site or organ system, separate
incision/excision, separate lesion, or separate injury (or area of injury in extensive
injuries) not ordinarily encountered or performed on the same day by the same
individual. However, when another already established modifier is appropriate, it
 should be used rather than modifier 59. Only if no more descriptive modifier is
available, and the use of modifier 59 best explains the circumstances, should modifier
59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a
separate and distinct E/M service with a nonE/M service performed on the same date,
see modifier 25.”

Modifier 59 and other NCCI-associated modifiers should NOT be used to bypass a PTP edit
unless the proper criteria for use of the modifier are met. Documentation in the medical
record must satisfy the criteria required by any NCCI-associated modifier that is used.
Modifier “-59” shall not be used with code 77427 Radiation treatment management, 5
treatments.

NCCI PTP edits define when 2 procedure HCPCS/CPT codes may not be reported together,
except under special circumstances. If an edit allows use of NCCI PTP-associated modifiers,
the 2 procedure codes may be reported together when the 2 procedures are performed at
different anatomic sites or different patient encounters. MAC processing systems use NCCI
PTP associated modifiers to allow payment of both codes of an edit. Modifiers 59 or -
X{EPSU} and other NCCI PTP-associated modifiers shall NOT be used to bypass an NCCI
PTP edit unless the proper criteria for use of the modifier are met. Documentation in the
medical record must satisfy the criteria required by any NCCI PTP-associated modifier used.
Some examples of the appropriate use of modifiers 59 or -X{EPSU} are contained in the
individual chapter policies.

One of the common misuses of modifier 59 is related to the portion of the definition of
modifier 59 allowing its use to describe “different procedure or surgery.” The code
descriptors of the 2 codes of a code pair edit usually represent different procedures or
surgeries. The edit indicates that the 2 procedures/surgeries cannot be reported together if
performed at the same anatomic site and same patient encounter. The provider/supplier
cannot use modifier 59 for such an edit based on the 2 codes being different
procedures/surgeries. However, if the 2 procedures/surgeries are performed at separate
anatomic sites or at separate patient encounters on the same date of service, modifiers 59 or -
X{ES} may be appended to indicate that they are different procedures/surgeries on that date
of service.

Modifier 59 or XS is used appropriately for different anatomic sites during the same
encounter only when procedures which are not ordinarily performed or encountered on the
same day are performed on different organs, or different anatomic regions, or in limited
situations on different, non-contiguous lesions in different anatomic regions of the same
organ.

There are several exceptions to this general principle about misuse of modifiers 59 or
X{EPSU} that apply to some code pair edits for procedures performed at the same patient
encounter.

(1) When a diagnostic procedure precedes a surgical or non-surgical therapeutic

procedure and is the basis on which the decision to perform the surgical or
nonsurgical therapeutic procedure is made, that diagnostic procedure may be
considered to be a separate and distinct procedure as long as (a) it occurs before the
therapeutic procedure and is not interspersed with services that are required for the
therapeutic intervention; (b) it clearly provides the information needed to decide
whether to proceed with the therapeutic procedure; and (c) it does not constitute a
service that would have otherwise been required during the therapeutic intervention.
If the diagnostic procedure is an inherent component of the surgical or non-surgical
therapeutic procedure, it shall not be reported separately.
(2) When a diagnostic procedure follows a surgical procedure or non-surgical
therapeutic procedure, that diagnostic procedure may be considered to be a separate
and distinct procedure as long as (a) it occurs after the completion of the therapeutic
procedure and is not interspersed with or otherwise commingled with services that
are only required for the therapeutic intervention, and (b) it does not constitute a
service that would have otherwise been required during the therapeutic intervention.
If the postprocedure diagnostic procedure is an inherent component or otherwise
included (or not separately payable) post-procedure service of the surgical procedure
or non-surgical therapeutic procedure, it shall not be reported separately.
(3) There is an appropriate use for modifiers 59 or -X{ES} that is applicable only to
codes for which the unit of service is a measure of time (e.g., per 15 minutes, per
hour). If 2 separate and distinct timed services are provided in separate and distinct
time blocks, modifier 59 may be used to identify the services. The separate and
distinct time blocks for the 2 services may be sequential to one another or split.
When the 2 services are split, the time block for 1 service may be followed by a time
block for the second service followed by another time block for the first service. All
Medicare rules for reporting timed services are applicable. For example, the total
time is calculated for all related timed services performed. The number of reportable
UOS is based on the total time, and these UOS are allocated between the
HCPCS/CPT codes for the individual services performed. The practitioner is not
permitted to perform multiple services, each for the minimal reportable time, and
report each of these as separate UOS.

Use of modifiers 59 or -X{ES} to indicate different procedures/surgeries does not require a

different diagnosis for each HCPCS/CPT coded procedure/surgery. Additionally, different
diagnoses are not adequate criteria for use of modifiers 59 or -X{EPSU}. The HCPCS/CPT
codes remain bundled unless the procedures/surgeries are performed at different anatomic
sites or separate patient encounters.

From an NCCI program perspective, the definition of different anatomic sites includes
different organs, different anatomic regions, or different lesions in the same organ. It does not
include treatment of contiguous structures in the same organ or anatomic region. For
example, treatment of the nail, nail bed, and adjacent soft tissue constitutes treatment of a
single anatomic site. Treatment of posterior segment structures in the ipsilateral eye
constitutes treatment of a single anatomic site.

If the same procedure is performed at different anatomic sites, it does not necessarily imply
that a HCPCS/CPT code may be reported with more than one unit of service for the
procedure. Determining whether additional UOS may be reported depends in part upon the
HCPCS/CPT code descriptor including the definition of the code’s unit of service when
present.

Example 1

The Column One/Column Two code edit with Column One CPT code 38221 (Diagnostic
bone marrow biopsy) and Column Two CPT code 38220 (Diagnostic bone marrow,
aspiration) includes two distinct procedures when performed at separate anatomic sites (e.g.,
contralateral iliac bones) or separate patient encounters. In these circumstances, it would be
acceptable to use modifier 59. However, if both 38221 and 38220 are performed on the same
iliac bone at the same patient encounter which is the usual practice, modifier 59 shall NOT be
used. Although CMS does not allow separate payment for CPT code 38220 with CPT code
38221 when bone marrow aspiration and biopsy are performed on the same iliac bone at a
single patient encounter, a physician may report CPT code 38222 (Diagnostic bone marrow;
biopsy(ies) and aspiration(s)).

Example 2

The Column One/Column Two code edit with Column One CPT code 11055 (Paring or
cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion) and Column Two
CPT code 11720 (Debridement of nail(s) by any method(s); 1 to 5) should not be reported
together for services performed on skin distal to and including the skin overlying the distal
interphalangeal joint of the same toe. Modifiers 59 or –X{EPSU} should not be used if a nail
is debrided on the same toe on which a hyperkeratotic lesion of the skin on or distal to the
distal interphalangeal joint is pared. Modifiers 59 or –XS may be reported with code 11720 if
1 to 5 nails are debrided, and a hyperkeratotic lesion is pared on a toe other than 1 with a
debrided toenail or the hyperkeratotic lesion is proximal to the skin overlying the distal
interphalangeal joint of a toe on which a nail is debrided.

e) Modifiers XE, XS, XP, XU: These modifiers were effective January 1, 2015. These
modifiers were developed to provide greater reporting specificity in situations where
modifier 59 was previously reported and may be used in lieu of modifier 59 whenever
possible. The modifiers are defined as follows:
 XE – “Separate Encounter, A service that is distinct because it occurred during a
separate encounter.” This modifier shall only be used to describe separate encounters
on the same date of service.
XS – “Separate Structure, A service that is distinct because it was performed on a
separate organ/structure”
XP – “Separate Practitioner, A service that is distinct because it was performed by a
different practitioner”
XU – “Unusual Non-Overlapping Service, the use of a service that is distinct because
it does not overlap usual components of the main service”

F. Standard Preparation/Monitoring Services for Anesthesia

With few exceptions, anesthesia HCPCS/CPT codes do not specify the mode of anesthesia
for a particular procedure. Regardless of the mode of anesthesia, preparation and monitoring
services are not separately reportable with anesthesia service HCPCS/CPT codes when
performed in association with the anesthesia service. However, if the provider of the
anesthesia service performs 1 or more of these services prior to and unrelated to the
anticipated anesthesia service or after the patient is released from the anesthesia practitioner’s
postoperative care, the service may be separately reportable with modifiers 59 or -X{EU}.

G. Anesthesia Service Included in the Surgical Procedure

Under the CMS Anesthesia Rules, with limited exceptions, Medicare does not allow separate
payment for anesthesia services performed by the physician who also furnishes the medical
or surgical service. In this case, payment for the anesthesia service is included in the payment
for the medical or surgical procedure. Likewise, under OPPS, payment for the anesthesia
service is generally included in the payment for the medical or surgical procedure. For
example, separate payment is not allowed for the physician’s performance of local, regional,
or most other anesthesia including nerve blocks if the physician also performs the medical or
surgical procedure. Medicare generally allows separate reporting for moderate conscious
sedation services (CPT codes 99151-99153) when provided by the same physician
performing a medical or surgical procedure except when the anesthesia service is bundled
into the procedure, e.g., radiation treatment management.

CPT codes describing anesthesia services (00100-01999) or services that are bundled into
anesthesia shall not be reported in addition to the surgical or medical procedure requiring the
anesthesia services if performed by the same physician. Examples of improperly reported
services that are bundled into the anesthesia service when anesthesia is provided by the
physician performing the medical or surgical procedure include introduction of needle or
intracatheter into a vein (CPT code 36000), venipuncture (CPT code 36410), intravenous
infusion/injection (CPT codes 96360-96368, 96374-96377) or cardiac assessment (e.g., CPT
codes 93000-93010, 9304093042). However, if these services are not related to the delivery
of an anesthetic agent or are not an inherent component of the procedure or global service,
they may be reported separately.

The physician performing a surgical or medical procedure shall not report an

epidural/subarachnoid injection (CPT codes 62320-62327) or nerve block (CPT codes
6440064530) for anesthesia for that procedure.

H. HCPCS/CPT Procedure Code Definition

The HCPCS/CPT code descriptors of 2 codes are often the basis of an NCCI PTP edit. If 2
HCPCS/CPT codes describe redundant services, they shall not be reported separately. Several
general principles follow:

1. A family of CPT codes may include a CPT code followed by one or more indented CPT
codes. The first CPT code descriptor includes a semicolon. The portion of the descriptor
of the first code in the family preceding the semicolon is a common part of the descriptor
for each subsequent code of the family. For example:

CPT code 70120 Radiologic examination, mastoids; less than

3 views per side
CPT code 70130 complete, minimum of 3 views per side

The portion of the descriptor preceding the semicolon (“Radiologic examination, mastoids”)
is common to both CPT codes 70120 and 70130. The difference between the 2 codes is the
portion of the descriptors following the semicolon. Often, as in this case, 2 codes from a
family may not be reported separately. A physician cannot report CPT codes 70120 and
70130 for a procedure performed on ipsilateral mastoids at the same patient encounter. It is
important to recognize, however, that there are numerous circumstances when it may be
appropriate to report more than one code from a family of codes. For example, CPT codes
70120 and 70130 may be reported separately if the 2 procedures are performed on
contralateral mastoids or at 2 separate patient encounters on the same date of service.

2. If a HCPCS/CPT code is reported, it includes all components of the procedure defined by

the descriptor. For example, CPT code 58291 includes a vaginal hysterectomy with
“removal of tube(s) and/or ovary(s).” A physician cannot report a salpingo-oophorectomy
(CPT code 58720) separately with CPT code 58291.
3. CPT code descriptors often define correct coding relationships where 2 codes may not be
reported separately with one another at the same anatomic site and/or same patient
encounter. A few examples follow:
a) A “partial” procedure is not separately reportable with a “complete” procedure.
 b) A “partial” procedure is not separately reportable with a “total” procedure.
c) A “unilateral” procedure is not separately reportable with a “bilateral” procedure.
d) A “single” procedure is not separately reportable with a “multiple” procedure.
e) A “with” procedure is not separately reportable with a “without” procedure.
f) An “initial” procedure is not separately reportable with a “subsequent” procedure.

I. CPT Manual and CMS Coding Manual Instructions

The CMS often publishes coding instructions in its rules, manuals, and notices. Physicians
must use these instructions when reporting services rendered to Medicare patients.

The “CPT Manual” also includes coding instructions which may be found in the
“Introduction,” individual chapters, and appendices. In individual chapters, the instructions
may appear at the beginning of a chapter, at the beginning of a subsection of the chapter, or
after specific CPT codes. Physicians should follow “CPT Manual” instructions unless the
CMS has provided different coding or reporting instructions.

The American Medical Association publishes “CPT Assistant” which contains coding
guidelines. The CMS does not review nor approve the information in this publication. In the
development of NCCI PTP edits, the CMS occasionally disagrees with the information in this
publication. If a physician uses information from “CPT Assistant” to report services rendered
to Medicare patients, it is possible that MACs may use different criteria to process claims.

J. CPT “Separate Procedure” Definition

If a CPT code descriptor includes the term “separate procedure,” the CPT code may not be
reported separately with a related procedure. The CMS interprets this designation to prohibit
the separate reporting of a “separate procedure” when performed with another procedure in
an anatomically related region often through the same skin incision, orifice, or surgical
approach.

A CPT code with the “separate procedure” designation may be reported with another
procedure if it is performed at a separate patient encounter on the same date of service or at
the same patient encounter in an anatomically unrelated area often through a separate skin
incision, orifice, or surgical approach. Modifiers 59 or -X{ES} (or a more specific modifier,
e.g., anatomic modifier) may be appended to the “separate procedure” CPT code to indicate
that it qualifies as a separately reportable service.

K. Family of Codes
The “CPT Manual” often contains a group of codes that describe related procedures that may
be performed in various combinations. Some codes describe limited component services, and
other codes describe various combinations of component services. Physicians must use
several principles in selecting the correct code to report:

1. A HCPCS/CPT code may be reported if and only if all services described by the code are
performed.
2. The HCPCS/CPT code describing the services performed shall be reported. A physician
shall not report multiple codes corresponding to component services if a single
comprehensive code describes the services performed. There are limited exceptions to this
rule which are specifically identified in this Manual.
3. HCPCS/CPT code(s) corresponding to component service(s) of other more
comprehensive HCPCS/CPT code(s) shall not be reported separately with the more
comprehensive HCPCS/CPT code(s) that include the component service(s).
4. If the HCPCS/CPT codes do not correctly describe the procedure(s) performed, the
physician shall report a “not otherwise specified” CPT code rather than a HCPCS/CPT
code that most closely describes the procedure(s) performed.

L. More Extensive Procedure

The “CPT Manual” often describes groups of similar codes differing in the complexity of the
service. Unless services are performed at separate patient encounters or at separate anatomic
sites, the less complex service is included in the more complex service and is not separately
reportable. Several examples of this principle follow:

1. If 2 procedures only differ in that 1 is described as a “simple” procedure and the other as a
“complex” procedure, the “simple” procedure is included in the “complex” procedure and
is not separately reportable unless the 2 procedures are performed at separate patient
encounters or at separate anatomic sites.
2. If 2 procedures only differ in that 1 is described as a “simple” procedure and the other as a
“complicated” procedure, the “simple” procedure is included in the “complicated”
procedure and is not separately reportable unless the 2 procedures are performed at
separate patient encounters or at separate anatomic sites.
3. If 2 procedures only differ in that 1 is described as a “limited” procedure and the other as
a “complete” procedure, the “limited” procedure is included in the “complete” procedure
and is not separately reportable unless the 2 procedures are performed at separate patient
encounters or at separate anatomic sites.
4. If 2 procedures only differ in that 1 is described as an “intermediate” procedure and the
other as a “comprehensive” procedure, the “intermediate” procedure is included in the
“comprehensive” procedure and is not separately reportable unless the 2 procedures are
performed at separate patient encounters or at separate anatomic sites.
5. If 2 procedures only differ in that 1 is described as a “superficial” procedure and the other
 as a “deep” procedure, the “superficial” procedure is included in the “deep” procedure and
is not separately reportable unless the 2 procedures are performed at separate patient
encounters or at separate anatomic sites.
6. If 2 procedures only differ in that 1 is described as an “incomplete” procedure and the
other as a “complete” procedure, the “incomplete” procedure is included in the
“complete” procedure and is not separately reportable unless the 2 procedures are
performed at separate patient encounters or at separate anatomic sites.
7. If 2 procedures only differ in that 1 is described as an “external” procedure and the other
as an “internal” procedure, the “external” procedure is included in the “internal”
procedure and is not separately reportable unless the 2 procedures are performed at
separate patient encounters or at separate anatomic sites.

M. Sequential Procedure
Some surgical procedures may be performed by different surgical approaches. If an initial
surgical approach to a procedure fails and a second surgical approach is used at the same
patient encounter, only the HCPCS/CPT code corresponding to the second surgical approach
may be reported. If there are different HCPCS/CPT codes for the 2 different surgical
approaches, the 2 procedures are considered “sequential,” and only the HCPCS/CPT code
corresponding to the second surgical approach may be reported. For example, a physician
may begin a cholecystectomy procedure using a laparoscopic approach and have to convert
the procedure to an open abdominal approach. Only the CPT code for the open
cholecystectomy may be reported. The CPT code for the failed laparoscopic cholecystectomy
is not separately reportable.

N. Laboratory Panel
The “CPT Manual” defines organ and disease specific panels of laboratory tests. If a
laboratory performs all tests included in one of these panels, the laboratory shall report the
CPT code for the panel. If the laboratory repeats 1 of these component tests as a medically
reasonable and necessary service on the same date of service, the CPT code corresponding to
the repeat laboratory test may be reported with modifier 91 appended (See Chapter X,
Section C (Organ or Disease Oriented Panels).

O. Misuse of Column Two Column Code with Column One

Code (Misuse of Code Edit Rationale)
The CMS manuals and instructions often describe groups of HCPCS/CPT codes that should
not be reported together for the Medicare program. Edits based on these instructions are often
included as misuse of a Column Two code with a Column One code.
A HCPCS/CPT code descriptor does not include exhaustive information about the code.
Physicians who are not familiar with a HCPCS/CPT code may incorrectly report the code in
a context different than intended. The NCCI program has identified HCPCS/CPT codes that
are incorrectly reported with other HCPCS/CPT codes as a result of the misuse of the
Column Two code with the Column One code. If these edits allow use of NCCI PTP-
associated modifiers (modifier indicator of “1”), there are limited circumstances when the
Column Two code may be reported on the same date of service as the Column One code.
Two examples follow:

1. Three or more HCPCS/CPT codes may be reported on the same date of service. Although
the Column Two code is misused if reported as a service associated with the Column One
code, the Column Two code may be appropriately reported with a third HCPCS/CPT code
reported on the same date of service. For example, the CMS limits separate payment for
use of the operating microscope for microsurgical techniques (CPT code 69990) to a
group of procedures listed in the online “Claims Processing Manual” (Chapter 12, Section
20.4.5 (Allowable Adjustments)). The NCCI program has edits with Column One codes
of surgical procedures not listed in this section of the manual and Column Two CPT code
of 69990. Some of these edits allow use of NCCI PTP-associated modifiers because the 2
services listed in the edit may be performed at the same patient encounter as a third
procedure for which CPT code 69990 is separately reportable.
2. There may be limited circumstances when the Column Two code is separately reportable
with the Column One code. For example, the NCCI program has an edit with Column
One CPT code of 47600 (Cholecystectomy) and Column Two CPT code of 12035 (Repair,
intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and
feet); 12.6 cm to 20.0 cm). If the patient has an abdominal wound in addition to and
separate from the cholecystectomy surgical incision, then it may be separately reportable
with CPT code 12035 using an NCCI PTP-associated modifier to bypass the edit. 47600
includes repair of the cholecystectomy surgical incision.

Misuse of code as an edit rationale may be applied to PTP edits where the Column Two code
is not separately reportable with the Column One code based on the nature of the Column
One coded procedure. This edit rationale may also be applied to code pairs where use of the
Column Two code with the Column One code is deemed to be a coding error.

P. Mutually Exclusive Procedures

Many procedure codes cannot be reported together because they are mutually exclusive of
each other. Mutually exclusive procedures cannot reasonably be performed at the same
anatomic site or same patient encounter. An example of a mutually exclusive situation is the
repair of an organ that can be performed by 2 different methods. Only one method can be
chosen to repair the organ. A second example is a service that can be reported as an “initial”
service or a “subsequent” service.

Q. Gender-Specific Procedures
The descriptor of some HCPCS/CPT codes includes a gender-specific restriction on the use
of the code. HCPCS/CPT codes specific for one gender should not be reported with
HCPCS/CPT codes for the opposite gender. For example, CPT code 53210 describes a total
urethrectomy including cystostomy in a female, and CPT code 53215 describes the same
procedure in a male. Since the patient cannot have both the male and female procedures
performed, the 2 CPT codes cannot be reported together.

R. Add-on Codes
Some codes in the “CPT Manual” are identified as “Add-on” Codes (AOCs), which describe
a service that can only be reported in addition to a primary procedure. “CPT Manual”
instructions specify the primary procedure code(s) for most AOCs. For other AOCs, the
primary procedure code(s) is (are) not specified. When the “CPT Manual” identifies specific
primary codes, the AOCs shall not be reported as a supplemental service for other
HCPCS/CPT codes not listed as a primary code.

AOCs permit the reporting of significant supplemental services commonly performed in

addition to the primary procedure. By contrast, incidental services that are necessary to
accomplish the primary procedure (e.g., lysis of adhesions in the course of an open
cholecystectomy) are not separately reportable with an AOC. Similarly, complications
inherent in an invasive procedure occurring during the procedure are not separately
reportable. For example, control of bleeding during an invasive procedure is considered part
of the procedure and is not separately reportable.

In general, NCCI PTP edits do not include edits with most AOCs because edits related to the
primary procedure(s) are adequate to prevent inappropriate payment for an add-on coded
procedure (i.e., if an edit prevents payment of the primary procedure code, the AOC shall not
be paid). However, the NCCI program does include edits for some AOCs when coding edits
related to the primary procedures must be supplemented. Examples include edits with add-on
HCPCS/CPT codes 69990 (Microsurgical techniques requiring use of operating microscope)
and 95940/95941/G0453 (Intraoperative neurophysiology testing).

HCPCS/CPT codes that are not designated as AOCs shall not be misused as an AOC to
report a supplemental service. A HCPCS/CPT code may be reported if and only if all services
described by the CPT code are performed. A HCPCS/CPT code shall not be reported with
another service because a portion of the service described by the HCPCS/CPT code was
performed with the other procedure. For example, if an ejection fraction is estimated from an
echocardiogram study, it would be inappropriate to additionally report CPT code 78472
(Cardiac blood pool imaging gated equilibrium; planar, single study at rest or stress (exercise
and/or pharmacologic), wall motion study plus ejection fraction, with or without additional
quantitative processing) with the echocardiography (e.g., CPT code 93307). Although the
procedure described by CPT code 78472 includes an ejection fraction, it is measured by
gated equilibrium with a radionuclide which is not used in echocardiography.

S. Excluded Service
The NCCI program does not generally address issues related to HCPCS/CPT codes
describing services that are excluded from Medicare coverage or are not otherwise
recognized for payment under the Medicare program.

T. Unlisted Procedure Codes

The “CPT Manual” includes codes to identify services or procedures not described by other
HCPCS/CPT codes. These unlisted procedure codes are generally identified as XXX99 or
XXXX9 codes and are located at the end of each section or subsection of the Manual. If a
physician provides a service that is not accurately described by other HCPCS/CPT codes, the
service shall be reported using an unlisted procedure code. A physician shall not report a CPT
code for a specific procedure if it does not accurately describe the service performed. It is
inappropriate to report the best fit HCPCS/CPT code unless it accurately describes the
service performed, and all components of the HCPCS/CPT code were performed. Since
unlisted procedure codes may be reported for a very diverse group of services, the NCCI
program generally does not include edits with these codes.

U. Modified, Deleted, and Added Code

Pairs/Edits – Information moved to Introduction chapter, Section (Purpose), Page
Intro-5 of this Manual

V. Medically Unlikely Edits (MUEs)

To lower the Medicare Fee-For-Service Paid Claims Error Rate, the CMS has established
units of service edits referred to as Medically Unlikely Edit(s)(MUEs).

An MUE for a HCPCS/CPT code is the maximum number of units of service (UOS) under
most circumstances allowable by the same provider for the same beneficiary on the same
date of service. The ideal MUE value for a HCPCS/CPT code is the unit of service that
allows the vast majority of appropriately coded claims to pass the MUE.

All claims submitted to MACs and Durable Medical Equipment (DME) MACs, and
outpatient facility services claims (Type of Bill 13X, 14X, 85X) are tested against MUEs.

Prior to April 1, 2013, each line of a claim was adjudicated separately against the MUE value
for the HCPCS/CPT code reported on that claim line. If the UOS on that claim line exceeded
the MUE value, the entire claim line was denied.

In the April 1, 2013, version of MUEs, the CMS began introducing date of service (DOS)
MUEs. Over time the CMS will convert many, but not all, MUEs to DOS MUEs. Since April
1, 2013, MUEs are adjudicated either as claim line edits or DOS edits. If the MUE is
adjudicated as a claim line edit, the UOS on each claim line are compared to the MUE value
for the HCPCS/CPT code on that claim line. If the UOS exceed the MUE value, all UOS on
that claim line are denied. If the MUE is adjudicated as a DOS MUE, all UOS on each claim
line for the same date of service for the same HCPCS/CPT code are summed, and the sum is
compared to the MUE value. If the summed UOS exceed the MUE value, all UOS for the
HCPCS/CPT code for that date of service are denied. Denials due to claim line MUEs or
DOS MUEs may be appealed to the local claims processing contractor. DOS MUEs are used
for HCPCS/CPT codes where it would be extremely unlikely that more UOS than the MUE
value would ever be performed on the same date of service for the same patient.

The MUE files on the CMS NCCI website display an “MUE Adjudication Indicator” (MAI)
for each HCPCS/CPT code. An MAI of “1” indicates that the edit is a claim line MUE. An
MAI of “2” or “3” indicates that the edit is a DOS MUE.

If a HCPCS/CPT code has an MUE that is adjudicated as a claim line edit, (i.e., MAI equal to
“1”) appropriate use of CPT modifiers (i.e., 59 or -X{EPSU}, 76, 77, 91, anatomic) may be
used to report the same HCPCS/CPT code on separate lines of a claim. Each line of the claim
with that HCPCS/CPT code will be separately adjudicated against the MUE value for that
HCPCS/CPT code. Claims processing contractors have rules limiting use of these modifiers
with some HCPCS/CPT codes.

MUEs for HCPCS codes with an MAI of “2” are absolute date of service edits. These are
“per day edits based on policy.” HCPCS codes with an MAI of “2” have been rigorously
reviewed and vetted within CMS and obtain this MAI designation because UOS on the same
date of service (DOS) in excess of the MUE value would be considered impossible because it
was contrary to statute, regulation, or subregulatory guidance. This subregulatory guidance
includes clear correct coding policy that is binding on both providers/suppliers and CMS
claims processing contractors. Limitations created by anatomical, or coding limitations are
incorporated in correct coding policy, both in the HIPAA mandated coding descriptors and
CMS-approved coding guidance as well as specific guidance in the CMS and NCCI manuals.
For example, it would be contrary to correct coding policy to report more than one unit of
service for CPT 94002 (Ventilation assist and management … initial day) because such use
could not accurately describe 2 initial days of management occurring on the same date of
service as would be required by the code descriptor. As a result, claims processing
contractors are instructed that an MAI of “2” denotes a claims processing restriction for
which override during processing, reopening, or redetermination would be contrary to CMS
policy.

MUEs for HCPCS codes with an MAI of “3” are “per day edits based on clinical
benchmarks.” MUEs assigned an MAI of “3” are based on criteria (e.g., nature of service,
prescribing information) combined with data such that it would be possible but medically
highly unlikely that higher values would represent correctly reported medically necessary
services. If contractors have evidence (e.g., medical review) that UOS in excess of the MUE
value were actually provided, were correctly coded and were medically necessary, the
contractor may bypass the MUE for a HCPCS code with an MAI of “3” during claim
processing, reopening, or redetermination, or in response to effectuation instructions from a
reconsideration or higher-level appeal.

Both the MAI and MUE value for each HCPCS/CPT code are based on one or more of the
following criteria:

(1) Anatomic considerations may limit UOS based on anatomic structures. For example:
a) The MUE value for an appendectomy is “1” since there is only 1 appendix.
b) The MUE for a knee brace is “2” because there are 2 knees and Medicare policy does
not cover back-up equipment.
c) The MUE value for a lumbar spine procedure reported per lumbar vertebra or per
lumbar interspace cannot exceed “5” since there are only 5 lumbar vertebrae or
interspaces.
d) The MUE value for a procedure reported per lung lobe cannot exceed “5” since there
are only 5 lung lobes (3 in right lung and 2 in left lung).
(2) CPT code descriptors/CPT coding instructions in the “CPT Manual” may limit UOS. For
example:
a) A procedure described as the “initial 30 minutes” would have an MUE value of “1”
because of the use of the term “initial.” A different code may be reported for
additional time.
b) If a code descriptor uses the plural form of the procedure, it must not be reported with
multiple UOS. For example, if the code descriptor states “biopsies,” the code is
reported with “1” unit of service regardless of the number of biopsies performed.
c) The MUE value for a procedure with “per day,” “per week,” or “per month” in its
code descriptor is “1” because MUEs are based on number of services per day of
service.
d) The MUE value of a code for a procedure described as “unilateral” is “1” if there is a
 different code for the procedure described as “bilateral.”
e) The code descriptors of a family of codes may define different levels of service, each
having an MUE of “1.” For example, CPT codes 78102-78104 describe bone marrow
imaging. CPT code 78102 is reported for imaging a “limited area.” CPT code 78103
is reported for imaging “multiple areas.” CPT code 78104 is reported for imaging the
“whole body.”
f) The MUE value for CPT code 86021 (Antibody identification; leukocyte antibodies)
is “1” because the code descriptor is plural including testing for any and all leukocyte
antibodies. On a single date of service only one specimen from a patient would be
tested for leukocyte antibodies.
g) When reporting codes, it is important to assure the accuracy of coding and the correct
UOS by selecting a code that accurately identifies the service performed based on
factors including but not limited to, the route of administration. For example, for
intravitreal injection of bevacizumab, select an intravitreal code (e.g., C9257) rather
than an intravenous code (e.g., J9035).
(3) Edits based on established CMS policies may limit UOS. For example:
a) The MUE value for a surgical or diagnostic procedure may be based on the bilateral
surgery indicator on the Medicare Physician Fee Schedule Database (MPFSDB).
i. If the bilateral surgery indicator is “0,” a bilateral procedure must be reported with
“1” unit of service. There is no additional payment for the code if reported as a
unilateral or bilateral procedure because of anatomy or physiology. Alternatively,
the code descriptor may specifically state that the procedure is a unilateral
procedure, and there is a separate code for a bilateral procedure.
ii. If the bilateral surgery indicator is “1,” a bilateral surgical procedure must be
reported with “1” unit of service and modifier 50 (bilateral modifier). A bilateral
diagnostic procedure may be reported with “1” unit of service and modifier 50 on
1 claim line, or “1” unit of service with modifier RT on 1 claim line plus “1” unit
of service and modifier LT on a second claim line.
iii. If the bilateral surgery indicator is “2,” a bilateral procedure must be reported with
“1” unit of service. The procedure is priced as a bilateral procedure because (1)
the code descriptor defines the procedure as bilateral; (2) the code descriptor
states that the procedure is performed unilaterally or bilaterally; or (3) the
procedure is usually performed as a bilateral procedure.
iv. If the bilateral surgery indicator is “3,” a bilateral surgical procedure must be
reported with “1” unit of service and modifier 50 (bilateral modifier). A bilateral
diagnostic procedure may be reported with “2” UOS on 1 claim line, “1” unit of
service and modifier 50 on 1 claim line, or 1 unit of service with modifier RT on 1
claim line plus “1” unit of service and modifier LT on a second claim line.
b) The MUE value for a code may be “1” where the code descriptor does not specify a
unit of service and the CMS considers the default UOS to be “per day.” c) The MUE
value for a code may be “0” because the code is listed as invalid, not covered,
 bundled, not separately payable, statutorily excluded, not reasonable and necessary,
etc. based on:
i. The Medicare Physician Fee Schedule Database
ii. OPPS Addendum B
iii. Alpha-Numeric HCPCS Code File
iv. DMEPOS Jurisdiction List
v. Medicare “Internet-Only Manual (“IOM”)
(4) The nature of an analyte may limit UOS and is in general determined by:
a) The nature of the specimen may limit the UOS. For example, CPT code 82575
describes a creatinine clearance test and has an MUE of “1” because the test requires
a twenty-four-hour urine collection; or
b) The physiology, pathophysiology, or clinical application of the analyte is such that a
maximum unit of service for a single date of service can be determined. For example,
the MUE for CPT code 82747 (RBC folic acid) is “1” because the test result would
not be expected to change during a single day, and thus it is not necessary to perform
the test more than once on a single date of service.
(5) The nature of a procedure/service may limit UOS and is in general determined by the
amount of time required to perform a procedure/service (e.g., overnight sleep studies) or
clinical application of a procedure/service (e.g., motion analysis tests).
a) The MUE for many surgical or medical procedures is “1” because the procedure is
rarely, if ever, performed more than 1 time per day (e.g., colonoscopy, motion
analysis tests).
b) The MUE value for a procedure is “1” because of the amount of time required to
perform the procedure (e.g., overnight sleep study).
(6) The nature of equipment may limit UOS and is in general determined by the number of
items of equipment that would be used. For example, the MUE value for a wheelchair
code is “1” because only 1 wheelchair is used at 1 time and Medicare policy does not
cover back-up equipment.
(7) Although clinical judgment considerations and determinations based on input from
numerous physicians and certified coders are sometimes initially used to establish some
MUE values, these values are subsequently validated or changed based on submitted
and/or paid claims data.
(8) Prescribing information is based on FDA labeling as well as off-label information
published in CMS-approved drug compendia. See below for additional information about
how prescribing information is used in determining the MUE values.
(9) Submitted and paid claims data (100%) from a six-month period is used to ascertain the
distribution pattern of UOS typically reported for a given HCPCS/CPT code.
(10)Published policies of the Durable Medical Equipment (DME) Medicare Administrative
Contractors (MACs) may limit UOS for some durable medical equipment, prosthetics,
orthotics, and supplies (DMEPOS). For example:
a) The MUE values for many ostomy and urological supply codes, nebulizer codes, and
 CPAP accessory codes are typically based on a three-month supply of items.
b) The MUE values for surgical dressings, parenteral and enteral nutrition,
immunosuppressive drugs, and oral anti-cancer drugs are typically based on a one-
month supply.
c) The MUE values take into account the requirement for reporting certain codes with
date spans.
d) The MUE value of a code may be “0” if the item is noncovered, not medically
necessary, or not separately payable.
e) The MUE value of a code may be “0” if the code is invalid for claim submission to
the DME MAC.

UOS denied based on an MUE may be appealed. Because a denial of services due to an MUE
is a coding denial, not a medical necessity denial, the presence of an Advanced Beneficiary
Notice of Noncoverage (ABN) shall not shift liability to the beneficiary for UOS denied
based on an MUE. If during reopening or redetermination medical records are provided with
respect to an MUE denial for an edit with an MAI of “3,” contractors will review the records
to determine if the provider actually furnished units in excess of the MUE, if the codes were
used correctly, and whether the services were medically reasonable and necessary. If the units
were actually provided but one of the other conditions is not met, a change in denial reason
may be warranted (for example, a change from the MUE denial based on incorrect coding to
a determination that the item/service is not reasonable and necessary under section 1862(a)
(1)). This may also be true for certain edits with an MAI of “1.” The CMS interprets the
notice delivery requirements under §1879 of the Social Security Act (the Act) as applying to
situations in which a provider expects the initial claim determination to be a reasonable and
necessary denial. Consistent with NCCI guidance, denials resulting from MUEs are not based
on any of the statutory provisions that give liability protection to beneficiaries under Section
1879 of the Act. Thus, ABN issuance based on an MUE is NOT appropriate. A
provider/supplier may not issue an ABN in connection with services denied due to an MUE
and cannot bill the beneficiary for UOS denied based on an MUE.

HCPCS J-code and drug related C and Q-code MUEs are based on prescribing information
and 100% claims data for a six-month period of time. Using the prescribing information, the
highest total daily dose for each drug was determined. This dose and its corresponding UOS
were evaluated against paid and submitted claims data. Some of the guiding principles used
in developing these edits are as follows:

(1) If the prescribing information defined a maximum daily dose, this value was used to
determine the MUE value. For some drugs there is an absolute maximum daily dose. For
others there is a maximum “recommended” or “usual” dose. In the latter 2 cases, the
daily dose calculation was evaluated against claims data.
(2) If the maximum daily dose calculation is based on actual body weight, a dose based on a
weight range of 110-150 kg was evaluated against the claims data. If the maximum daily
 dose calculation is based on ideal body weight, a dose based on a weight range of 90-110
kg was evaluated against claims data. If the maximum daily dose calculation is based on
body surface area (BSA), a dose based on a BSA range of 2.4-3.0 square meters was
evaluated against claims data.
(3) For drugs where the maximum daily dose is based on patient response or need,
prescribing information and claims data were used to establish the MUE values.
(4) Published off-label use of a drug was considered for the maximum daily dose
calculation.
(5) The MUE values for some drug codes are set to “0.” The rationale for such values
include but are not limited to: discontinued manufacture of drug, non-FDA-approved
compounded drug, practitioner MUE values for oral antineoplastic, oral anti-emetic, and
oral immune suppressive drugs which should be billed to the DME MACs, outpatient
hospital MUE values for inhalation drugs which should be billed to the DME MACs, and
Practitioner/ASC MUE values for HCPCS C codes describing medications that would
not be related to a procedure performed in an ASC.

Non-drug-related HCPCS/CPT codes may be assigned an MUE of “0” for a variety of

reasons including, but not limited to, outpatient hospital MUE value for a surgical procedure
only performed as an inpatient procedure, noncovered service, bundled service, DME MUE
value for implanted devices and items related to implanted devices which should not be
billed to the DME MACs, or packaged service.

The MUE files on the CMS NCCI website display an “Edit Rationale” for each HCPCS/CPT
code. Although an MUE may be based on several rationales, only one is displayed on the
website. One of the listed rationales is “Data.” This rationale indicates that 100% claims data
from a six-month period of time was the major factor in determining the MUE value. If a
physician appeals an MUE denial for a HCPCS/CPT code where the MUE is based on
“Data,” the reviewer will usually confirm that (1) the correct code is reported; (2) the correct
UOS are used; (3) the number of reported UOS were performed; and (4) all UOS were
medically reasonable and necessary.

The first MUEs were implemented January 1, 2007. Additional MUEs are added on a
quarterly basis on the same schedule as NCCI PTP updates. Prior to implementation
proposed MUEs are sent to numerous national healthcare organizations for a 60-day review
and comment period.

Many surgical procedures may be performed bilaterally. Instructions in the CMS “IOM”
(Publication 100-04 “Medicare Claims Processing Manual,” Chapter 12
(Physicians/Nonphysician Practitioners), Section 40.7.B. and Chapter 4 (Part B Hospital
(Including Inpatient Hospital Part B and OPPS)), Section 20.6.2 require that bilateral surgical
procedures be reported using modifier 50 with one unit of service unless the code descriptor
defines the procedure as “bilateral.” If the code descriptor defines the procedure as a
“bilateral” procedure, it shall be reported with one unit of service without modifier 50. If a
bilateral surgical procedure is performed at different sites bilaterally, one unit of service may
be reported for each site. That is, the HCPCS/CPT code may be reported with modifier 50
and one unit of service for each site at which it was performed bilaterally.

Some A/B MACs allow providers to report repetitive services performed over a range of
dates on a single line of a claim with multiple UOS. If a provider reports services in this
fashion, the provider should report the “from date” and “to date” on the claim line.
Contractors are instructed to divide the UOS reported on the claim line by the number of
days in the date span and round to the nearest whole number. This number is compared to the
MUE value for the code on the claim line.

Providers/Suppliers billing services to the DME MACs typically report some HCPCS codes
for supply items for a period exceeding a single day. The DME MACs have billing rules for
these codes. For some codes the DME MACs require that the “from date” and “to date” be
reported. The MUEs for these codes are based on the maximum number of UOS that may be
reported for a single date of service. For other codes the DME MACs permit multiple days’
supply items to be reported on a single claim line where the “from date” and “to date” are the
same. The DME MACs have rules allowing supply items for a maximum number of days to
be reported at one time for each of these types of codes. The MUE values for these codes are
based on the maximum number of days that may be reported at one time. As with all MUEs,
the MUE value does not represent a utilization guideline. Providers/suppliers shall not
assume that they may report UOS up to the MUE value on each date of service.
Providers/suppliers may only report supply items that are medically reasonable and
necessary.

Most MUE values are set so that a provider or supplier would only very occasionally have a
claim line denied. If a provider encounters a code with frequent denials due to the MUE or
frequent use of a CPT modifier to bypass the MUE, the provider or supplier should consider
the following: (1) Is the HCPCS/CPT code being used correctly? (2) Is the unit of service
being counted correctly? (3) Are all reported services medically reasonable and necessary?
and (4) Why does the provider’s or supplier’s practice differ from national patterns? A
provider or supplier may choose to discuss these questions with the local Medicare contractor
or a national healthcare organization whose members frequently perform the procedure.

Most MUE values are published on the CMS MUE webpage. However, some MUE values
are not published and are confidential. These values shall not be published in oral or written
form by any party that acquires one or more of them.

MUEs are not utilization edits. Although the MUE value for some codes may represent the
commonly reported UOS (e.g., MUE of “1” for appendectomy), the usual UOS for many
HCPCS/CPT codes is less than the MUE value. Claims reporting UOS less than the MUE
value may be subject to review by claims processing contractors, Unified Program Integrity
Contractor (UPICS), Recovery Audit Contractors (RACs), and Department of Justice (DOJ).

Since MUEs are coding edits, rather than medical necessity edits, claims processing
contractors may have UOS edits that are more restrictive than MUEs. In such cases, the more
restrictive claims processing contractor edit would be applied to the claim. Similarly, if the
MUE is more restrictive than a claims processing contractor edit, the more restrictive MUE
would apply.

W. Add-on Code Edit Tables

Add-on Codes (AOCs) are discussed in Chapter I, Section R (Add-on Codes). The CMS
publishes a list of AOCs and their primary codes annually prior to January 1. The list is
updated quarterly based on the AMA’s “CPT Errata” documents or implementation of new
HCPCS/CPT add-on codes. The CMS identifies AOCs and their primary codes based on
“CPT Manual” instructions, CMS interpretation of HCPCS/CPT codes, and CMS coding
instructions.

The NCCI program includes 3 AOC Edit Tables, 1 table for each of 3 “Types” of AOC. Each
table lists the AOC with its primary codes. An AOC is a HCPCS/CPT code that describes a
service that, with rare exception, is performed in conjunction with another primary service by
the same practitioner. An AOC is rarely eligible for payment if it is the only procedure
reported by a practitioner.

The “Type I AOC Edit Table” lists AOCs for which the “CPT Manual” or HCPCS tables
define all acceptable primary codes. Claims processing contractors should not allow other
primary codes with Type I AOCs. CPT code 99292 (Critical care, evaluation, and
management of the critically ill or critically injured patient; each additional 30 minutes (List
separately in addition to code for primary service)) is included as a Type I AOC since its only
primary code is CPT code 99291 (Critical care, evaluation, and management of the critically
ill or critically injured patient; first 30-74 minutes). For Medicare purposes, CPT code 99292
may be eligible for payment to a physician without CPT code 99291 if another physician of
the same specialty and physician group reports and is paid for CPT code 99291.

The “Type II AOC Edit Table” lists AOC for which the “CPT Manual” and HCPCS tables do
not define any primary codes. Claims processing contractors should develop their own lists
of acceptable primary codes.

The “Type III AOC Edit Table” lists AOCs for which the “CPT Manual” or HCPCS tables
define some, but not all, acceptable primary codes. Claims processing contractors should
allow the listed primary codes for these AOCs but may develop their own lists of additional
acceptable primary codes.
Although the AOC and primary code are normally reported for the same date of service,
there are unusual circumstances where the 2 services may be reported for different dates of
service (e.g., CPT codes 99291 and 99292).

The first AOC edit tables were implemented April 1, 2013. For subsequent years, new AOC
edit tables will be published to be effective for January 1 of the new year based on changes in
the new year’s “CPT Manual”. The CMS also issues quarterly updates to the AOC edit tables
if required due to publication of new HCPCS/CPT codes or changes in add-on codes or their
primary codes. The changes in the quarterly update files (April 1, July 1, or October 1) are
retroactive to the implementation date of that year’s annual AOC edit files unless the files
specify a different effective date for a change. Since the first AOC edit files were
implemented on April 1, 2013, changes in the July 1 and October 1 quarterly updates for
2013 were retroactive to April 1, 2013 unless the files specified a different effective date for
a change.
FIGURE CREDITS
1. From Little J, et al: Dental Management of the Medically Compromised Patient, ed 9, St. Louis, 2017, Mosby.
(Courtesy Medtronic, Minneapolis)
2. From Franklin I, Dawson P, Rodway A: Essentials of Clinical Surgery, ed 2, St. Louis, 2012, Saunders.
3. Modified from Grosfeld J, et al: Pediatric Surgery, ed 7, Philadelphia, 2012, Mosby.
4. Modified from Hsu J, Michael J, Fisk J: AAOS Atlas of Orthoses and Assistive Devices, ed 4, Philadelphia, 2008,
Mosby.
5. From Wold G: Basic Geriatric Nursing, ed 5, St. Louis, 2011, Mosby.
6. Modified from Roberts J, Hedges J: Clinical Procedures in Emergency Medicine, ed 6, St. Louis, 2013, Saunders.
7. From Auerbach P: Wilderness Medicine, ed 7, Philadelphia, 2016, Mosby. (Courtesy Black Diamond Equipment, Ltd.)
8. (Original to book).
9. Modified from Abeloff M, et al: Clinical Oncology, ed 5, Philadelphia, 2013, Churchill Livingstone.
10. (Original to book).
11. Modified from Duthie E, Katz P, Malone M: Practice of Geriatrics, ed 4, Philadelphia, 2007, Saunders.
12. Modified from Roberts J, Hedges J: Clinical Procedures in Emergency Medicine, ed 6, St. Louis, 2013, Saunders.
13. From Young A, Proctor D: Kinn’s The Medical Assistant, ed 13, St. Louis, 2016, Saunders.
14. From Bonewit-West K: Clinical Procedures for Medical Assistants, ed 9, Philadelphia, 2015, WB Saunders.
15. From Roberts J, Hedges J: Clinical Procedures in Emergency Medicine, ed 6, St. Louis, 2013, Saunders.
16. From Yeo: Shackelford’s Surgery of the Alimentary Tract, ed 7, Philadelphia, 2012, Saunders.
17. Redrawn from Bragg D, Rubin P, Hricak H: Oncologic Imaging, ed 2, 2002, Saunders.
18. From Roberts J, Hedges J: Clinical Procedures in Emergency Medicine, ed 6, St. Louis, 2013, Saunders. (Courtesy
Atrium Medical Corp., Hudson, NH 03051)
19. A From Auerbach P: Wilderness Medicine, ed 7, Philadelphia, 2016, Mosby. B Modified from Hsu J, Michael J, Fisk J:
AAOS Atlas of Orthoses and Assistive Devices, ed 4, Philadelphia, 2008, Mosby.
20. Modified from Lusardi M, Nielsen C: Orthotics and Prosthetics in Rehabilitation, ed 3, St. Louis, 2013, Butterworth-
Heinemann.
21. Modified from Lusardi M, Nielsen C: Orthotics and Prosthetics in Rehabilitation, ed 3, St. Louis, 2013, Butterworth-
Heinemann.
22. Modified from Lusardi M, Nielsen C: Orthotics and Prosthetics in Rehabilitation, ed 3, St. Louis, 2013, Butterworth-
Heinemann.
23. From Buck C: The Next Step, Advanced Medical Coding 2023/2024 edition, St. Louis, 2023, Elsevier.
24. From Jardins T: Clinical Manifestations and Assessment of Respiratory Disease, ed 7, St. Louis, 2015, Elsevier.
25. From Hsu J, Michael J, Fisk J: AAOS Atlas of Orthoses and Assistive Devices, ed 4, Philadelphia, 2008, Mosby.
26. Modified from Hsu J, Michael J, Fisk J: AAOS Atlas of Orthoses and Assistive Devices, ed 4, Philadelphia, 2008,
Mosby.
27. Modified from Hsu J, Michael J, Fisk J: AAOS Atlas of Orthoses and Assistive Devices, ed 4, Philadelphia, 2008,
Mosby.
28. From Didomenico L, Gatlyak N: “End-Stage Ankle Arthritis.” Clinics in Podiatric Medicine and Surgery 29.3 (2012):
391-412.
29. Cameron M, Monroe L: Physical Rehabilitation for the Physical Therapist Assistant, ed 1, St. Louis, 2011, Saunders.
30. From Rowe D, Jadhav A: “Care of the Adolescent with Spina Bifida.” Pediatric Clinics of North America 55.6 (2008):
1359-374.
31. Modified from Lusardi M, Nielsen C: Orthotics and Prosthetics in Rehabilitation, ed 3, St. Louis, 2013, Butterworth-
Heinemann.
32. From Hsu J, Michael J, Fisk J: AAOS Atlas of Orthoses and Assistive Devices, ed 4, Philadelphia, 2008, Mosby.
33. (Original to book.)
34. From Hochberg M: Rheumatology, ed 5, Philadelphia, 2011, Mosby.
35. Modified from Hsu J, Michael J, Fisk J: AAOS Atlas of Orthoses and Assistive Devices, ed 4, Philadelphia, 2008,
 Mosby.
36. From Coughlin M, Mann R, Saltzman C: Surgery of the Foot and Ankle, ed 9, Philadelphia, 2013, Mosby.
37. From Canale S: Campbell’s Operative Orthopaedics, ed 12, St. Louis, 2012, Mosby.
38. From Sorrentino S, Gorek B: Mosby’s Textbook for Long-term Care Nursing Assistants, ed 7, St. Louis, 2014, Mosby.
39. From Pedretti L, Pendleton H, Schultz-Krohn W: Pedretti’s Occupational Therapy: Practice Skills for Physical
Dysfunction, ed 7, St. Louis, 2013, Elsevier.
40. From Skirven T: Rehabilitation of the Hand and Upper Extremity, ed 6, Philadelphia, 2010, Mosby.
41. From Lusardi M, Nielsen C: Orthotics and Prosthetics in Rehabilitation, ed 3, St. Louis, 2013, Butterworth-
Heinemann. (Courtesy Michael Curtain)
42. Schickendantz M: “Diagnosis and Treatment of Elbow Disorders in the Overhead Athlete.” Hand Clinics 18.1 (2002):
65-75.
43. Modified from Bland K, Copeland E: The Breast: Comprehensive Management of Benign and Malignant Disorders, ed
4, St. Louis, 2009, Saunders.
44. From Shah J, Patel S, Singh B, Shah J: Jatin Shah’s Head and Neck Surgery and Oncology, ed 4, Philadelphia, 2012,
Mosby, 2012. From Subburaj K, Nair C, Rajesh S, Ravi B: “Rapid Development of Auricular Prosthesis Using CAD
and Rapid Prototyping Technologies.” International Journal of Oral and Maxillofacial Surgery 36.10 (2007): 938-43.
45. From Weinzweig J: Plastic Surgery Secrets, ed 2, Philadelphia, 2010, Hanley & Belfus, p 543.
46. Modified from Mann D: Heart Failure: A Companion to Braunwald’s Heart Disease, ed 3, Philadelphia, 2015,
Saunders.
47. Modified from Roberts J, Hedges J: Clinical Procedures in Emergency Medicine, ed 6, Philadelphia, 2013, Saunders.
48. From Yanoff M, Duker J: Ophthalmology, ed 4, St. Louis, 2014, Mosby.
49. From Feldman M, Friedman L, Brandt L: Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, ed 10,
Philadelphia, 2015, Saunders.
50. From Katz V, et al: Comprehensive Gynecology, ed 7, Philadelphia, 2016, Mosby.
51. From Young A, Proctor D: Kinn’s The Medical Assistant, ed 13, St. Louis, 2016, Saunders.
52. From Yanoff M, Duker J: Ophthalmology, ed 4, St. Louis, 2014, Mosby.