Coverage Policies

Important! Please note:

Current policies effective through April 30, 2024.

Take me to policies effective May 1, 2024.

Use the index below to search for coverage information on specific medical conditions.

High-Tech Imaging: High-Tech Imaging services are administered by National Imaging Associates, Inc. (NIA). For coverage information and authorizations, click here.

Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

QualChoice follows care guidelines published by MCG Health.

Clinical Practice Guidelines for Providers (PDF)

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:



Effective Date: 01/01/2008	Title: Routine & Complex Office Procedures
Revision Date: 01/01/2016	Document: BI222:00
CPT Code(s):
Public Statement
*Effective Date:* a) This policy will apply to all services performed for groups new or renewing on or after 1-1-2015 which will become the new effective date. b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply. 1) Procedures and lab tests performed by your doctor in the office may be routine or relatively complex. Similarly, medications given in the doctor’s office may be routine and common, or more complex and less often used. You may have different benefits depending on what sort of procedure is performed; your schedule of benefits tells you what cost share is required for different types of procedures. 2) Providers need guidance to make, and to help members make, this distinction. This policy provides a list of all procedures, tests, and medications that are considered “routine” and all procedures, tests, and medications that are considered “complex.” Any procedures, tests, or medications not listed in this policy are considered “advanced.” If you have questions about a particular procedure, you may call our Customer Service Department for additional information.
Medical Statement
1) QualChoice administered plans may require different cost shares for different types of procedures, in addition to the cost share for the office visit. It is important for physicians to be able to distinguish (and help members to distinguish) which procedures will be covered under the copayment as opposed to those that will not be --- requiring additional payment from the member. To facilitate that, the list of services classified as “routine” or “complex” is attached to this policy. 2) These rules do not override any coverage exclusions, limitations, restrictions, preauthorization requirements or other rules that specify when a code will or will not be determined to be a covered service. ROUTINE OFFICE PROCEDURES AND MEDICATIONS CPT CODE CODE DESCRIPTION 11719 Trimming of nondystrophic nails, any number 11720 Debridement of nail(s) by any method(s); one to five 11721 Debridement of nail(s) by any method(s); six or more 11740 Evacuation of subungual hematoma 11900 Injection, intralesional; up to and including seven lesions 11901 Injection, intralesional; more than seven lesions 16000 Initial treatment, first degree burn, when no more than local treatment is required 16020 Dressings and / or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area) 17000 Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesion (e.g., actinic keratoses); first lesion 17003 Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesion (e.g., actinic keratoses); second through 14 lesions, each (List separately in addition to code for first lesion) 17004 Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesion (e.g., actinic keratoses); 15 or more lesions 17110 Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions; up to 14 lesions 17111 Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions; 15 or more lesions 17250 Chemical cauterization of granulation tissue (proud flesh, sinus or fistula) 20526 Injection, therapeutic (e.g., local anesthetic, corticosteroid), carpal tunnel 20550 Injection(s); single tendon sheath, or ligament, aponeurosis (e.g., plantar "fascia") 20551 Injection(s); single tendon origin / insertion 20552 Injection(s); single or multiple trigger point(s), one or two muscle(s) 20553 Injection(s); single or multiple trigger point(s), three or more muscle(s) 20612 Aspiration and / or injection of ganglion cyst(s) any location 29130 Application of finger splint; static 29131 Application of finger splint; dynamic 29200 Strapping; thorax 29240 Strapping; shoulder 29260 Strapping; elbow or wrist 29280 Strapping; hand or finger 29520 Strapping; hip 29530 Strapping; knee 29540 Strapping; ankle and/or ft 29550 Strapping; toes 29580 Strapping; Unna boot 30300 Removal foreign body, intranasal; office type procedure 36000 Introduction of needle or intracatheter, vein 36415 Collection of venous blood by venipuncture 36416 Collection of capillary blood specimen (e.g., finger, heel, ear stick) 46500 Injection of sclerosing solution, hemorrhoids 46900 Destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; chemical 46910 Destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; electrodessication 46916 Destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; cryosurgery 46917 Destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; laser surgery 51701 Insertion of non-indwelling bladder catheter (e.g. straight catheterization for residual urine) 64550 Application of surface (transcutaneous) neurostimulator 65205 Removal of foreign body, external eye; conjunctival superficial 69200 Removal foreign body from external auditory canal; without general anesthesia 69209 Removal impacted cerumen using irrigation/lavage, unilateral (new code 1/1/16) 69210 Removal impacted cerumen (separate procedure), one or both ears 70030 X-ray eye for foreign body 70100 X-ray exam of jaw 70110 X-ray exam of jaw 70120 X-ray exam of mastoids 70130 X-ray exam of mastoids 70134 X-ray exam of middle ear 70140 X-ray exam of facial bones 70150 X-ray exam of facial bones 70160 X-ray exam of nasal bones 70170 X-ray exam of tear duct 70190 X-ray exam of eye sockets 70200 X-ray exam of eye sockets 70210 X-ray exam of sinuses 70220 X-ray exam of sinuses 70240 X-ray exam, pituitary saddle 70250 X-ray exam of skull 70260 X-ray exam of skull 70300 X-ray exam of teeth 70310 X-ray exam of teeth 70320 Full mouth x-ray of teeth 70328 X-ray exam of jaw joint 70330 X-ray exam of jaw joints 70332 X-ray exam of jaw joint 70355 Panoramic x-ray of jaws 70360 X-ray exam of neck 71010 Chest x-ray 71015 Chest x-ray 71020 Chest x-ray 71021 Chest x-ray 71022 Chest x-ray 71030 Chest x-ray 71035 Chest x-ray 71100 X-ray exam of ribs 71101 X-ray exam of ribs/chest 71110 X-ray exam of ribs 71111 X-ray exam of ribs/chest 71120 X-ray exam of breastbone 71130 X-ray exam of breastbone 72010 X-ray exam of spine (code deleted 1/1/16) 72020 X-ray exam of spine 72040 X-ray exam of neck spine 72050 X-ray exam of neck spine 72052 X-ray exam of neck spine 72069 X-ray exam of trunk spine (code deleted 1/1/16) 72070 X-ray exam of thoracic spine 72072 X-ray exam of thoracic spine 72074 X-ray exam of thoracic spine 72080 X-ray exam of trunk spine 72081 X-ray exam of spine, entire thoracic and lumbar, including skull, cervical & sacral spine if performed; 1 view (new code 1/1/16) 72082 X-ray exam of spine, entire thoracic and lumbar, including skull, cervical & sacral spine if performed; 2 or 3 views (new code 1/1/16) 72083 X-ray exam of spine, entire thoracic and lumbar, including skull, cervical & sacral spine if performed; 4 or 5 views (new code 1/1/16) 72084 X-ray exam of spine, entire thoracic and lumbar, including skull, cervical & sacral spine if performed; minimum of 6 views (new code 1/1/16) 72090 X-ray exam of trunk spine (code deleted 1/1/16) 72100 X-ray exam of lower spine 72110 X-ray exam of lower spine 72114 X-ray exam of lower spine 72120 X-ray exam of lower spine 72170 X-ray exam of pelvis 72190 X-ray exam of pelvis 72200 X-ray exam sacroiliac joints 72202 X-ray exam sacroiliac joints 72220 X-ray exam of tailbone 73000 X-ray exam of collar bone 73010 X-ray exam of shoulder blade 73020 X-ray exam of shoulder 73030 X-ray exam of shoulder 73050 X-ray exam of shoulders 73060 X-ray exam of humerus 73070 X-ray exam of elbow 73080 X-ray exam of elbow 73090 X-ray exam of forearm 73092 X-ray exam of arm, infant 73100 X-ray exam of wrist 73110 X-ray exam of wrist 73120 X-ray exam of hand 73130 X-ray exam of hand 73140 X-ray exam of finger(s) 73500 X-ray exam of hip (code deleted 1/1/16) 73501 Radiologic examination, hip, unilateral, with pelvis when performed; 1 view (new code 1/1/16) 73502 Radiologic examination, hip, unilateral, with pelvis when performed; 2 - 3 views (new code 1/1/16) 73503 Radiologic examination, hip, unilateral, with pelvis when performed; minimum of 4 views (new code 1/1/16) 73510 X-ray exam of hip (code deleted 1/1/16) 73520 X-ray exam of hips (code deleted 1/1/16) 73521 Radiologic examination, hips, bilateral, with pelvis when performed; 2 views (new code 1/1/16) 73522 Radiologic examination, hips, bilateral, with pelvis when performed; 3-4 views (new code 1/1/16) 73523 Radiologic examination, hips, bilateral, with pelvis when performed; minimum of 5 views (new code 1/1/16) 73530 X-ray exam of hip (code deleted 1/1/16) 73540 X-ray exam of pelvis & hips (code deleted 1/1/16) 73550 X-ray exam of thigh (code deleted 1/1/16) 73551 Radiologic examination, femur; 1 view (new code 1/1/16) 73552 Radiologic examination, femur; minimum 2 views (new code 1/1/16) 73560 X-ray exam of knee, 1 or 2 73562 X-ray exam of knee, 3 73564 X-ray exam, knee, 4 or more 73565 X-ray exam of knees 73590 X-ray exam of lower leg 73592 X-ray exam of leg, infant 73600 X-ray exam of ankle 73610 X-ray exam of ankle 73620 X-ray exam of foot 73630 X-ray exam of foot 73650 X-ray exam of heel 73660 X-ray exam of toe(s) 74000 X-ray exam of abdomen 74010 X-ray exam of abdomen 74020 X-ray exam of abdomen 74022 X-ray exam series, abdomen 76010 X-ray, nose to rectum 80047 Metabolic panel ionized ca 80048 Metabolic panel total ca 80050 General health panel 80051 Electrolyte panel 80053 Comprehensive metabolic panel 80055 Obstetric panel 80061 Lipid panel 80069 Renal function panel 80074 Acute hepatitis panel 80076 Hepatic function panel 80081 Obstetric panel (includes HIV testing) (new code 1/1/16) 80100 Drug screen, qualitative/multi (code deleted 1/1/15) 80102 Drug confirmation (code deleted 1/1/15) 80300 Drug screen, any # of drug classes from Drug Class List A; any # of non-TLC devices or procedures (e.g., immunoassay) capable of being read by direct optical observation, incl. instrument-assisted when performed, per dt of svc 81000 Urinalysis, nonauto w/scope 81001 Urinalysis, auto w/scope 81002 Urinalysis nonauto w/o scope 81003 Urinalysis, auto, w/o scope 81005 Urinalysis 81007 Urine screen for bacteria 81015 Microscopic exam of urine 81020 Urinalysis, glass test 81025 Urine pregnancy test 82043 Microalbumin, quantitative 82044 Microalbumin, semiquant 82075 Assay of breath ethanol 82247 Bilirubin, total 82248 Bilirubin, direct 82270 Occult blood, feces 82271 Occult blood, other sources 82272 Occult blood feces, 1-3 tests 82274 Assay test for blood, fecal 82306 Assay of vitamin D 82310 Assay of calcium 82330 Assay of calcium 82465 Assay, blood/serum cholesterol 82550 Assay of Creatine Kinase (CK), (CPK); total 82565 Assay of creatinine 82570 Assay of urine creatinine 82575 Creatinine clearance test 82607 Vitamin B-12 82652 Assay of dihydroxyvitamin d 82670 Assay of estradiol 82671 Assay of estrogens 82672 Assay of estrogen 82677 Assay of estriol 82679 Assay of estrone 82728 Ferritin 82746 Blood folic acid serum 82947 Assay, glucose, blood quant 82948 Reagent strip/blood glucose 82950 Glucose test 82962 Glucose blood test 82977 Assay of GGT 83001 Gonadotropin (FSH) 83002 Gonadotropin (LH) 83013 H pylori (c-13), breath 83036 Glycosylated hemoglobin test 83498 Assay of progesterone 83499 Assay of progesterone 83540 Assay of iron 83550 Iron binding test 83615 Lactate (LD) (LDH) enzyme 83655 Assay of lead 83718 Assay of lipoprotein 83719 Assay of blood lipoprotein 83721 Assay of blood lipoprotein 83735 Assay of magnesium 84030 Assay of blood pku 84075 Assay alkaline phosphatase 84100 Assay of phosphorus 84132 Assay of serum potassium 84144 Assay of progesterone 84146 Assay of prolactin 84152 Assay of psa, complexed 84153 Assay of psa, total 84154 Assay of psa, free 84155 Assay of protein, serum 84156 Assay of protein, urine 84233 Assay of estrogen 84234 Assay of progesterone 84295 Assay of serum sodium 84300 Assay of urine sodium 84402 Assay of testosterone 84403 Assay of total testosterone 84432 Assay of thyroglobulin 84436 Assay of total thyroxine 84437 Assay of neonatal thyroxine 84439 Assay of free thyroxine 84442 Assay of thyroid activity 84443 Assay thyroid stim hormone 84450 Transferase (AST) (SGOT) 84460 Alanine amino (ALT) (SGPT) 84466 Assay of transferrin 84478 Assay of triglycerides 84479 Assay of thyroid (t3 or t4) 84480 Assay, triiodothyronine (t3) 84481 Free assay (FT-3) 84482 T3 reverse 84520 Assay of urea nitrogen 84525 Urea nitrogen semi-quant 84540 Assay of urine/urea-n 84550 Assay of blood/uric acid 85004 Automated diff wbc count 85007 Bl smear w/diff wbc count 85008 Bl smear w/o diff wbc count 85009 Manual diff wbc count b-coat 85013 Spun microhematocrit 85014 Hematocrit 85018 Hemoglobin 85025 Complete cbc w/auto diff wbc 85027 Complete cbc, automated 85032 Manual cell count, each 85041 Automated rbc count 85044 Manual reticulocyte count 85045 Automated reticulocyte count 85046 Reticyte/hgb concentrate 85048 Automated leukocyte count 85049 Automated platelet count 85055 Reticulated platelet assay 85610 Prothrombin time 85611 Prothrombin test 85651 Rbc sed rate, nonautomated 85652 Rbc sed rate, automated 85660 RBC sickle cell test 86140 C-reactive protein 86580 TB intradermal test 87210 Smear, wet mount, saline/ink 87430 Strep a ag, eia 87804 Influenza assay w/optic 87810 Chylmd trach assay w/optic 87850 Neisseria gonorrhoeae assay w/optic 87880 Strep a assay w/optic 90460 Immunization administration thru 18 yrs. of age via any route of administration, w/ counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered 90461 Immunization administration thru 18 yrs. of age via any route of administration, w/ counseling by physician or other qualified health care professional; each additional vaccine or toxoid component administered (add-on code) 90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine / toxoid) 90472 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine / toxoid) (List separately in addition to code for primary procedure 90473 Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine / toxoid) 90474 Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine / toxoid) (List separately in addition to code for primary procedure) 90620 Meningococcal recombinant protein and outer membrane vesicle vaccine, serogroup B, 2 dose schedule, IM Use 90621 Meningococcal recombinant lipoprotein vaccine, serogroup B, 3 dose schedule, IM Use 90625 DTaP-HepB-IPV, IM use (new code 1/1/16) 90630 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, Intradermal Use 90632 Hep a vaccine, adult im 90633 Hep a vacc, ped/adol, 2 dose 90634 Hep a vacc, ped/adol, 3 dose 90636 Hep a/hep b vacc, adult im 90645 Hib vaccine, hboc, im (code deleted 1/1/16) 90646 Hib vaccine, prp-d, im (code deleted 1/1/16) 90647 Hib vaccine, prp-omp, im 90648 Hib vaccine, prp-t, im 90649 H papilloma vacc 3 dose im 90651 Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (HPV), 3 dose schedule, IM Use 90655 Flu vaccine no preserv 6-35m 90656 Flu vaccine no preserv 3 & > 90657 Flu vaccine, 3 yrs., im 90658 Flu vaccine, 3 yrs. & >, im 90660 Flu vaccine, nasal 90669 Pneumococcal vacc, ped <5 (code deleted 1/1/16) 90680 Rotavirus vacc 3 dose, oral 90690 Typhoid vaccine, oral 90691 Typhoid vaccine, im 90697 Diphtheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, Haemophilus influenza type B PRP-OMP conjugate vaccine, and hepatitis B vaccine (DTaP-IPV-Hib-HepB), IM Use 90700 Dtap vaccine, < 7 yrs., im 90702 Dt vaccine < 7, im 90703 Tetanus vaccine, im (code deleted 1/1/16) 90704 Mumps vaccine, sc (code deleted 1/1/16) 90705 Measles vaccine, sc (code deleted 1/1/16) 90706 Rubella vaccine, sc (code deleted 1/1/16) 90707 Mmr vaccine, sc 90708 Measles-rubella vaccine, sc (code deleted 1/1/16) 90710 Mmrv vaccine, sc 90713 Poliovirus, ipv, sc/im 90714 Td vaccine no prsrv >/= 7 im 90715 Tdap vaccine >7 im 90716 Chicken pox vaccine, sc 90721 Dtap/hib vaccine, im (code deleted 1/1/16) 90723 Dtap-hep b-ipv vaccine, im 90732 Pneumococcal vaccine 90733 Meningococcal vaccine, sc 90734 Meningococcal vaccine, im 90736 Zoster vacc, sc 90740 Hepb vacc, ill pat 3 dose im 90743 Hep b vacc, adol, 2 dose, im 90744 Hepb vacc ped/adol 3 dose im 90746 Hep b vaccine, adult, im 90747 Hepb vacc, ill pat 4 dose im 90748 Hep b/hib vaccine, im 92015 Determination of refractive state 92020 Gonioscopy (separate procedure) 92025 Computerized corneal topography, unilateral or bilateral, with interpretation and report 92060 Sensorimotor examination with multiple measurements of ocular deviation (e.g., restrictive or paretic muscle with diplopia) with interpretation and report (separate procedure) 92071 Fitting of contact lens for treatment of ocular surface disease 92072 Fitting of contact lens for management of keratoconus, initial fitting 92081 Visual field examination, unilateral or bilateral, with interpretation and report; limited examination (e.g., tangent screen, Autoplot, arc perimeter, or single stimulus level automated test, such as Octopus 3 or 7 equivalent) 92082 Visual field examination, unilateral or bilateral, with interpretation and report; intermediate examination (e.g., at least 2 isopters on Goldmann perimeter, or semiquantitative, automated suprathreshold screening program, Humphrey suprathreshold automatic diagnostic test, Octopus program 33) 92083 Visual field examination, unilateral or bilateral, with interpretation and report; extended examination (e.g., Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30°, or quantitative, automated threshold perimetry, Octopus program G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2, or 30/60-2 92145 Corneal hysteresis determination, by air impulse stimulation, unilateral or bilateral, with interpretation and report 92133 Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral 92134 Scanning computerized ophthalmic diagnostic imaging, retina, with interpretation and report, unilateral or bilateral 92136 Ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation 92140 Provocative tests for glaucoma, with interpretation and report, without tonography 92225 Ophthalmoscopy, extended, with retinal drawing (e.g., for retinal detachment, melanoma), with interpretation and report; initial 92226 Ophthalmoscopy, extended, with retinal drawing (e.g., for retinal detachment, melanoma), with interpretation and report; subsequent 92260 Ophthalmodynamometry 92283 Color vision examination, extended, e.g., anomaloscope or equivalent 92284 Dark adaptation examination with interpretation and report 92285 External ocular photography with interpretation and report for documentation of medical progress (e.g., close-up photography, slit lamp photography, goniophotography, stereo-photography) 92504 Binocular microscopy (separate diagnostic procedure) 92531 Spontaneous nystagmus, including gaze 92551 Screening test, pure tone, air only 92552 Pure tone audiometry (threshold); air only 92553 Pure tone audiometry (threshold); air and bone 92555 Speech audiometry threshold; 92556 Speech audiometry threshold; with speech recognition 92557 Comprehensive audiometry threshold evaluation and speech recognition (92553 and 92556 combined) 92560 Bekesy audiometry; screening 92561 Bekesy audiometry; diagnostic 92562 Loudness balance test, alternate binaural or monaural 92563 Tone decay test 92564 Short increment sensitivity index (SISI) 92565 Stenger test, pure tone 92567 Tympanometry (impedance testing) 92568 Acoustic reflex testing; threshold 92570 Acoustic immittance testing, includes tympanometry (impedence testing), acoustic reflex threshold testing, and acoustic reflex decay testing 92571 Filtered speech test 92572 Staggered spondaic word test 92575 Sensorineural acuity level test 92576 Synthetic sentence identification test 92577 Stenger test, speech 92579 Visual reinforcement audiometry (VRA) 92582 Conditioning play audiometry 92583 Select picture audiometry 92625 Assessment of tinnitus (including pitch, loudness matching, and masking) 93000 Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report 93005 Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report 93010 Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only 93040 Rhythm ECG, one to three leads; with interpretation and report 93041 Rhythm ECG, one to three leads; tracing only without interpretation and report 93042 Rhythm ECG, one to three leads; interpretation and report only 94010 Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation 94150 Vital capacity, total (separate procedure) 94200 Maximum breathing capacity, maximal voluntary ventilation 94726 Plethysmography for determination of lung volumes and, when performed, airway resistance 94760 Noninvasive ear or pulse oximetry for oxygen saturation; single determination 96372 Diagnostic, prophylactic, or therapeutic injection, subcutaneous or intramuscular 99070 Supplies/materials, provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered 99172 Visual function screening, automated or semi-automated bilateral quantitative determination of visual acuity, ocular alignment, color vision by pseudoisochromatic plates, and field of vision (may include all or some screening of the determination(s) for contract sensitivity, vision under glare) 99173 Screening test of visual acuity, quantitative, bilateral 99177 Instrument-based ocular screening, bilateral; with on-site analysis (new code 1/1/16) G0008 Admin Influenza Virus Vac G0009 Admin Pneumococcal Vaccine G0101 Ca Screen; Pelvic/Breast Exam G0102 Prostate Ca Screening; Dre G0103 Psa, Total Screening G0108 Diab Manage Trn Per Indiv G0145 Scr C/V Cyto, Thin layer, Rescr G0202 Screening mammography, producing direct digital image, bilateral, all views, professional component G0475 HIV antigen/antibody, combination assay, screening (new code 1/1/16) G0476 Infectious agent detection by nucleic acid; HPV, high risk types for cervical cancer screening, must be performed in addition to pap test (new code 1/1/16) J0120 Tetracyclin Injection J0171 Injection, adrenalin, epinephrine, 0.1 mg J0280 Aminophyllin 250 Mg Inj J0290 Ampicillin 500 Mg Inj J0295 Ampicillin Sodium Per 1.5 Gm J0330 Succinycholine Chloride Inj J0461 Injection, atropine sulfate, 0.01 mg J0558 Injection, penicillin G benzathine & penicillin G procaine, 100,000 units J0561 Injection, penicillin G benzathine, 100,000 units J0571 Buprenorphine, oral, 1 mg J0572 Buprenorphine/naloxone, oral , less than or equal to 3 mg J0573 Buprenorphine/naloxone, oral , greater than 3 mg but less than or equal to 6 mg J0574 Buprenorphine/naloxone, oral, greater than 6 mg, but less than or equal to 10 mg J0575 Buprenorphine/naloxone, oral, greater than 10 mg J0595 Injection, butorphanol tartrate, 1 mg J0610 Calcium Gluconate Injection J0640 Leucovorin Calcium Injection J0670 Inj Mepivacaine Hcl/10 Ml J0690 Cefazolin Sodium Injection J0695 Ceftolozane 50mg and tazobactam 25 mg Injection (new code 1/1/16) J0696 Ceftriaxone Sodium Injection J0697 Sterile Cefuroxime Injection J0698 Cefotaxime Sodium Injection J0702 Betamethasone Acet & Sod Phosp J0714 Ceftazidime and avibactam, 0.5g/0.125g Injection (new code 1/1/16) J0715 Ceftizoxime Sodium / 500 Mg J0720 Chloramphenicol Sodium Injec J0770 Colistimethate Sodium Inj J0780 Prochlorperazine Injection J0833 Injection, Cosyntropin, not otherwise specified, 0.25 mg J0875 Dalbavancin 5mg Injection (new code 1/1/16) J0945 Brompheniramine Maleate Inj J1000 Depo-Estradiol Cypionate Inj J1020 Methylprednisolone 20 Mg Inj J1030 Methylprednisolone 40 Mg Inj J1040 Methylprednisolone 80 Mg Inj J1050 Injection, Medroxyprogesterone acetate, 1 mg J1060 Testosterone Cypionate 1 Ml (PA required; see BI 305) (code deleted 1/1/15) J1070 Testosterone Cypionate 100 Mg (PA required; see BI 305) (code deleted 1/1/15) J1071 Injection, Testosterone Cypionate, 1 mg J1080 Testosterone Cypionate 200 Mg (PA required; see BI305) (code deleted 1/1/15) J1094 Injection, Dexamethasone Acetate, 1 Mg J1100 Dexamethasone Sodium Phos J1110 Inj Dihydroergotamine Mesylt J1120 Acetazolamid Sodium Injection J1160 Digoxin Injection J1170 Hydromorphone Injection J1200 Diphenhydramine Hcl Injection J1245 Dipyridamole Injection J1250 Inj Dobutamine Hcl/250 Mg J1380 Estradiol Valerate 10 Mg Inj J1410 Inj Estrogen Conjugate 25 Mg J1435 Injection Estrone Per 1 Mg J1450 Fluconazole J1453 Fosaprepitant injection, 1 mg J1580 Garamycin Gentamicin Inj J1642 Inj Heparin Sodium Per 10 U J1644 Inj Heparin Sodium Per 1000u J1645 Dalteparin Sodium J1670 Tetanus Immune Globulin Inj J1720 Hydrocortisone Sodium Succ I J1815 Injection, Insulin, Per 5 Units J1885 Ketorolac Tromethamine Inj J1940 Furosemide Injection J2001 Injection, lidocaine hcl for intravenous infusion, 10 mg J2010 Lincomycin Injection J2060 Lorazepam Injection J2150 Mannitol Injection J2175 Meperidine Hydrochl /100 Mg J2180 Meperidine/Promethazine Inj J2250 Inj Midazolam Hydrochloride J2270 Morphine Sulfate Injection J2274 Injection, Morphine Sulfate, Preservative-Free for Epidural/Intrathecal Use, 10 mg J2275 Morphine Sulfate Injection (code deleted 1/1/15) J2300 Inj Nalbuphine Hydrochloride J2360 Orphenadrine Injection J2370 Phenylephrine Hcl Injection J2407 Oritavancin, 10mg Injection (new code 1/1/16) J2550 Promethazine Hcl Injection J2675 Inj Progesterone Per 50 Mg J2710 Neostigmine Methylslfte Inj J2720 Inj Protamine Sulfate/10 Mg J2765 Metoclopramide Hcl Injection J2780 Ranitidine Hydrochloride Inj J2810 Inj Theophylline Per 40 Mg J2920 Methylprednisolone Injection J2930 Methylprednisolone Injection J2950 Promazine Hcl Injection J3010 Fentanyl Citrate Injection J3090 Tedizolid phosphate, 1mg Injection (new code 1/1/16) J3105 Terbutaline Sulfate Inj J3120 Testosterone Enanthate Inj (PA required; see BI 305) (code deleted 1/1/15) J3121 Injection, Testosterone Enanthate, 1 mg J3130 Testosterone Enanthate Inj (PA required; see BI 305) (code deleted 1/1/15) J3145 Injection, Testosterone Undecanoate, 1 mg J3230 Chlorpromazine Hcl Injection J3260 Tobramycin Sulfate Injection J3301 Triamcinolone Acetonide Inj J3302 Triamcinolone Diacetate Inj J3303 Triamcinolone Hexacetonl Inj J3360 Diazepam Injection J3410 Hydroxyzine Hcl Injection J3420 Cyanocobalamin Injection J3430 Vitamin K Phytonadione Inj J3475 Inj Magnesium Sulfate J3480 Inj Potassium Chloride J7030 Normal Saline Solution Infus J7042 5% Dextrose/Normal Saline J7050 Normal Saline Solution Infus J7060 5% Dextrose/Water J7070 D5w Infusion J7120 Ringers Lactate Infusion J7121 5% Dextrose in alctated ringers infusion, up to 1000 cc (new code 1/1/16) J7300 Intraut Copper Contraceptive J7302 Levonorgestrel-releasing intrauterine contraceptive system, 52 mg J7340 Carbidopa 5mg/levodopa 20mg enteral suspension (new code 1/1/16) J7503 Tacrolimus, extended release, oral 0.25mg (new code 1/1/16) J7512 Prednisone, immediate release or delayed release, oral, 1mg (new code 1/1/16) J7609 Albuterol comp unit J7611 Albuterol concentrated form J7613 Albuterol unit dose J7614 Levalbuterol unit dose COMPLEX OFFICE PROCEDURES AND MEDICATIONS CPT CODE CODE DESCRIPTION 10021 Fine needle aspiration; without imaging guidance 10040 Acne surgery (e.g., marsupialization, opening or removal of multiple milia, comedones, cysts, pustules) 10060 Incision and drainage of abscess (e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia; simple or single 10080 Incision and drainage of pilonidal cyst; simple 10120 Incision and removal of foreign body, subcutaneous tissues; simple 10140 Incision and drainage of hematoma, seroma or fluid collection 10160 Puncture aspiration of abscess, hematoma, bulla, or cyst 11000 Debridement of extensive eczematous or infected skin; up to 10% of body surface 11001 Debridement of extensive eczematous or infected skin; each additional 10% of the body surface (List separately in addition to code for primary procedure) 11055 Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single lesion 11056 Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); two to four lesions 11057 Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); more than four lesions 11100 Biopsy of skin, subcutaneous tissue and / or mucous membrane (including simple closure), unless otherwise listed; single lesion 11101 Biopsy of skin, subcutaneous tissue and / or mucous membrane (including simple closure), unless otherwise listed; each separate / additional lesion (List separately in addition to code for primary procedure) 11200 Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions 11201 Removal of skin tags, multiple fibrocutaneous tags, any area; each additional ten lesions (List separately in addition to code for primary procedure) 11300 Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm or less 11301 Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.6 to 1.0 cm 11302 Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 1.1 to 2.0 cm 11305 Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less 11306 Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.6 cm TO 1.0 CM 11310 Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less 11311 Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm 11400 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less 11401 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.6 to 1.0 cm 11402 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 1.1 to 2.0 cm 11420 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less 11421 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cm 11440 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.5 cm or less 11441 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.6 to 1.0 cm 11976 Removable, Implantable Contraceptive Capsules 12001 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and / or extremities (including hands and feet); 2.5 cm or less 12002 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and / or extremities (including hands and feet); 2.6 cm to 7.5 cm 12011 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and / or mucous membranes; 2.5 cm or less 17106 Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); less than 10 sq. cm 17260 Destruction, malignant lesion (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 0.5 cm or less 17261 Destruction, malignant lesion (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 0.6 to 1.0 cm 17270 Destruction, malignant lesion (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less 17280 Destruction, malignant lesion (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less 17340 Cryotherapy (CO2 slush, liquid N2) for acne 19000 Puncture aspiration of cyst of breast; 19001 Puncture aspiration of cyst of breast; each additional cyst (List separately in addition to code for primary procedure) 20600 Arthrocentesis, aspiration and / or injection; small joint or bursa (e.g., fingers, toes) 20605 Arthrocentesis, aspiration and / or injection; intermediate joint or bursa (e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa) 20610 Arthrocentesis, aspiration and / or injection; major joint or bursa (e.g., shoulder, hip, knee joint, subacromial bursa) 30901 Control nasal hemorrhage, anterior, simple (limited cautery and / or packing) any method 30903 Control nasal hemorrhage, anterior, complex (extensive cautery and / or packing) any method 36400 Venipuncture, younger than age 3 years, necessitating physician`s skill, not to be used for routine venipuncture; femoral or jugular vein 36405 Venipuncture, younger than age 3 years, necessitating physician`s skill, not to be used for routine venipuncture; scalp vein 36406 Venipuncture, younger than age 3 years, necessitating physician`s skill, not to be used for routine venipuncture; other vein 36410 Venipuncture, younger than age 3 years, necessitating physician`s skill (separate procedure), for diagnostic or therapeutic purposes (not to be used for routine venipuncture) 36591 Collection of blood specimen from a completely implantable venous access device 36593 Declotting by thrombolytic agent of implanted vascular access device or catheter 42650 Dilation of salivary duct 42660 Dilation and catheterization of salivary duct, with or without injection 43450 Dilation of esophagus, by unguided sound or bougie, single or multiple passes 43453 Dilate esophagus, over guide wire 43756 Duodenal intubation and aspiration, diagnostic, includes image guidance; single specimen 43757 Duodenal intubation and aspiration, diagnostic, includes image guidance; collection of multiple fractional specimens w/ pancreatic or gallbladder stimulation, single or double lumen tube, includes drug administration 43760 Change gastrostomy tube 43761 Repositioning of the gastric feeding tube, any method, through the duodenum for enteric nutrition 45190 Destruction of rectal tumor, transanal approach 45520 Perirectal injection of sclerosing solution for prolapsed 46083 Incision of thrombosed hemorrhoid, external 46220 Papillectomy or excision of single tag, anus (separate procedure) 46230 Excision of external hemorrhoid tags and / or multiple papillae 46320 Enucleation or excision of external thrombotic hemorrhoid 46600 Anoscopy; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) 46922 Destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; surgical excision 46930 Destruction of internal hemorrhoid(s) by thermal energy 51100 Aspiration of bladder; by needle 51702 Insertion of temporary indwelling bladder catheter; simple (e.g., Foley) 51736 Simple uroflowmetry (UFR) (e.g., stop-watch flow rate, mechanical uroflowmeter) 51798 Measurement of post-voiding residual urine and / or bladder capacity by ultrasound, non-imaging 53660 Dilation of female urethra including suppository and / or instillation; initial 53661 Dilation of female urethra including suppository and / or instillation; subsequent 56442 Hymenotomy, simple incision 56605 Biopsy of vulva/perineum (separate procedure); one lesion 56606 Biopsy of vulva/perineum (separate procedure); each separate additional lesion (List separately in addition to code for primary procedure) 57150 Irrigation of vagina and / or application of medicament for treatment of bacterial, parasitic, or fungoid disease 57160 Fitting and insertion of pessary or other intravaginal support device 57170 Diaphragm or cervical cap fitting with instructions 58100 Endometrial sampling (biopsy) with or without endocervical sampling (biopsy), without cervical dilation, any method (separate procedure) 58300 Insertion of intrauterine device 58301 Removal of intrauterine device 65210 Removal of foreign body, external eye; conjunctival embedded (includes concretions), subconjunctival, or scleral nonperforating 65220 Removal of foreign body, external eye; corneal, without slit lamp 65222 Removal of foreign body, external eye; corneal, with slit lamp 69100 Biopsy of external ear 68801 Dilation of lacrimal duct 68810 Probing of lacrimal duct 70350 X-ray head for orthodontia 70371 Speech evaluation, complex 74190 X-ray exam of peritoneum 74710 X-ray measurement of pelvis 74775 X-ray exam of perineum 77071 X-ray stress view 77072 X-rays for bone age 77073 X-rays, bone length studies 77074 X-rays, bone survey, limited 77075 X-rays, bone survey complete 77076 X-rays, bone survey, infant 77077 Joint survey, single view 80103 Drug analysis, tissue prep (code deleted 1/1/15) 80150 Assay of amikacin 80152 Assay of amitriptyline (code deleted 1/1/15) 80154 Assay of benzodiazepines (code deleted 1/1/15) 80156 Assay, carbamazepine, total 80157 Assay, carbamazepine, free 80158 Assay of cyclosporine 80160 Assay of desipramine (code deleted 1/1/15) 80162 Assay of digoxin 80164 Assay, dipropylacetic acid 80166 Assay of doxepin (code deleted 1/1/15) 80168 Assay of ethosuximide 80170 Assay of gentamicin 80172 Assay of gold (code deleted 1/1/15) 80173 Assay of haloperidol 80174 Assay of imipramine (code deleted 1/1/15) 80176 Assay of lidocaine 80178 Assay of lithium 80182 Assay of nortriptyline (code deleted 1/1/15) 80184 Assay of phenobarbital 80185 Assay of phenytoin, total 80186 Assay of phenytoin, free 80188 Assay of primidone 80190 Assay of procainamide 80192 Assay of procainamide 80194 Assay of quinidine 80195 Assay of sirolimus 80196 Assay of salicylate (code deleted 1/1/15) 80197 Assay of tacrolimus 80198 Assay of theophylline 80200 Assay of tobramycin 80201 Assay of topiramate 80202 Assay of vancomycin 80299 Quantitative assay, drug 80320 Alcohol confirmatory drug testing 80321 Alcohol biomarkers confirmatory drug testing; 1 or 2 80322 Alcohol biomarkers confirmatory drug testing; 3 or more 80323 Alkaloids confirmatory drug testing, not otherwise specified 80324 Amphetamines confirmatory drug testing; 1 or 2 80325 Amphetamines confirmatory drug testing; 3 or 4 80326 Amphetamines confirmatory drug testing; 5 or more 80327 Anabolic steroids confirmatory drug testing; 1 or 2 80328 Anabolic steroids confirmatory drug testing; 3 or more 80329 Analgesics, non-opioid confirmatory drug testing; 1 or 2 80330 Analgesics, non-opioid confirmatory drug testing; 3 to 5 80331 Analgesics, non-opioid confirmatory drug testing; 6 or more 80335 Antidepressants, tricyclic and other cyclicals confirmatory drug testing; 1 or 2 80336 Antidepressants, tricyclic and other cyclicals confirmatory drug testing; 3 - 5 80337 Antidepressants, tricyclic and other cyclicals confirmatory drug testing; 6 or more 80339 Antiepileptics, not otherwise specified confirmatory drug testing; 1 - 3 80340 Antiepileptics, not otherwise specified confirmatory drug testing; 4 - 6 80341 Antiepileptics, not otherwise specified confirmatory drug testing; 7 or more 80342 Antipsychotics, not otherwise specified confirmatory drug testing; 1 - 3 80343 Antipsychotics, not otherwise specified confirmatory drug testing; 4 - 6 80344 Antipsychotics, not otherwise specified confirmatory drug testing; 7 or more 80345 Barbiturates confirmatory drug testing 80346 Benzodiazepines confirmatory drug testing; 1 - 12 80347 Benzodiazepines confirmatory drug testing; 13 or more 80353 Cocaine confirmatory drug testing 80358 Methadone confirmatory drug testing 80361 Opiates confirmatory drug testing; 1 or more 80362 Opioids and Opiate analogs confirmatory drug testing; 1 or 2 80363 Opioids and Opiate analogs confirmatory drug testing; 3 or 4 80364 Opioids and Opiate analogs confirmatory drug testing; 5 or more 80369 Skeletal muscle relaxants confirmatory drug testing; 1 or 2 80370 Skeletal muscle relaxants confirmatory drug testing; 3 or more 80375 Drug(s) or substance(s), definitive, qualitative or quantitative drug testing, NOS; 1 - 3 80400 Acth stimulation panel 80402 Acth stimulation panel 80406 Acth stimulation panel 80408 Aldosterone suppression eval 80410 Calcitonin stimul panel 80412 CRH stimulation panel 80414 Testosterone response 80415 Estradiol response panel 80416 Renin stimulation panel 80417 Renin stimulation panel 80418 Pituitary evaluation panel 80420 Dexamethasone panel 80422 Glucagon tolerance panel 80424 Glucagon tolerance panel 80426 Gonadotropin hormone panel 80428 Growth hormone panel 80430 Growth hormone panel 80432 Insulin suppression panel 80434 Insulin tolerance panel 80435 Insulin tolerance panel 80436 Metyrapone panel 80438 TRH stimulation panel 80439 TRH stimulation panel 80440 TRH stimulation panel (code deleted 1/1/15) 80500 Lab pathology consultation 80502 Lab pathology consultation 81050 Urinalysis, volume measure 81099 Urinalysis test procedure 82000 Assay of blood acetaldehyde (code deleted 1/1/15) 82003 Assay of acetaminophen (code deleted 1/1/15) 82009 Test for acetone/ketones 82010 Acetone assay 82013 Acetylcholinesterase assay 82016 Acylcarnitines, qual 82017 Acylcarnitines, quant 82024 Assay of acth 82030 Assay of adp & amp 82040 Assay of serum albumin 82042 Assay of urine albumin 82045 Albumin, ischemia modified 82055 Assay of ethanol (code deleted 1/1/15) 82085 Assay of aldolase 82088 Assay of aldosterone 82101 Assay of urine alkaloids (code deleted 1/1/15) 82103 Alpha-1-antitrypsin, total 82104 Alpha-1-antitrypsin, pheno 82105 Alpha-fetoprotein, serum 82106 Alpha-fetoprotein, amniotic 82107 Alpha-fetoprotein l3 82108 Assay of aluminum 82120 Amines, vaginal fluid qual 82127 Amino acid, single qual 82128 Amino acids, mult qual 82131 Amino acids, single quant 82135 Assay, aminolevulinic acid 82136 Amino acids, quant, 2-5 82139 Amino acids, quan, 6 or more 82140 Assay of ammonia 82143 Amniotic fluid scan 82145 Assay of amphetamines (code deleted 1/1/15) 82150 Assay of amylase 82154 Androstanediol glucuronide 82157 Assay of androstenedione 82160 Assay of androsterone 82163 Assay of angiotensin II 82164 Angiotensin I enzyme test 82172 Assay of apolipoprotein 82175 Assay of arsenic 82180 Assay of ascorbic acid 82190 Atomic absorption 82205 Assay of barbiturates (code deleted 1/1/15) 82232 Assay of beta-2 protein 82239 Bile acids, total 82240 Bile acids, cholylglycine 82252 Fecal bilirubin test 82261 Assay of biotinidase 82286 Assay of bradykinin 82300 Assay of cadmium 82306 Vitamin D; 25 hydroxy, includes fraction(s), if performed 82308 Assay of calcitonin 82331 Calcium infusion test 82340 Assay of calcium in urine 82355 Calculus analysis, qual 82360 Calculus assay, quant 82365 Calculus spectroscopy 82370 X-ray assay, calculus 82373 Assay, c-d transfer measure 82374 Assay, blood carbon dioxide 82375 Assay, blood carbon monoxide 82376 Test for carbon monoxide 82378 Carcinoembryonic antigen 82379 Assay of carnitine 82380 Assay of carotene 82382 Assay, urine catecholamines 82383 Assay, blood catecholamines 82384 Assay, three catecholamines 82387 Assay of cathepsin-d 82390 Assay of ceruloplasmin 82397 Chemiluminescent assay 82415 Assay of chloramphenicol 82435 Assay of blood chloride 82436 Assay of urine chloride 82438 Assay, other fluid chlorides 82441 Test for chlorohydrocarbons 82480 Assay, serum cholinesterase 82482 Assay, rbc cholinesterase 82485 Assay, chondroitin sulfate 82486 Gas/liquid chromatography (code deleted 1/1/16) 82487 Paper chromatography (code deleted 1/1/16) 82488 Paper chromatography (code deleted 1/1/16) 82489 Thin layer chromatography (code deleted 1/1/16) 82491 Chromotography, quant, sing (code deleted 1/1/16) 82492 Chromotography, quant, mult (code deleted 1/1/16) 82495 Assay of chromium 82507 Assay of citrate 82520 Assay of cocaine (code deleted 1/1/15) 82523 Collagen crosslinks 82525 Assay of copper 82528 Assay of corticosterone 82530 Cortisol, free 82533 Total cortisol 82540 Assay of creatine 82541 Column chromatography, qual (code deleted 1/1/16) 82542 Column chromatography, quant 82543 Column chromatograph/isotope (code deleted 1/1/16) 82544 Column chromatograph/isotope (code deleted 1/1/16) 82552 Assay of cpk in blood 82553 Creatine, MB fraction 82554 Creatine, isoforms 82585 Assay of cryofibrinogen 82595 Assay of cryoglobulin 82600 Assay of cyanide 82608 B-12 binding capacity 82610 Cystatin c 82615 Test for urine cystines 82626 Dehydroepiandrosterone 82627 Dehydroepiandrosterone 82633 Desoxycorticosterone 82634 Deoxycortisol 82638 Assay of dibucaine number 82646 Assay of dihydrocodeinone (code deleted 1/1/15) 82649 Assay of dihydromorphinone (code deleted 1/1/15) 82651 Assay of dihydrotestosterone (code deleted 1/1/15) 82652 Vitamin D; 1, 25 dihydroxy, includes fraction(s), if performed 82654 Assay of dimethadione (code deleted 1/1/15) 82656 Pancreatic elastase, fecal 82657 Enzyme cell activity 82658 Enzyme cell activity, ra 82664 Electrophoretic test 82666 Assay of epiandrosterone (code deleted 1/1/15) 82668 Assay of erythropoietin 82690 Assay of ethchlorvynol (code deleted 1/1/15) 82693 Assay of ethylene glycol 82696 Assay of etiocholanolone 82705 Fats/lipids, feces, qual 82710 Fats/lipids, feces, quant 82715 Assay of fecal fat 82725 Assay of blood fatty acids 82726 Long chain fatty acids 82731 Assay of fetal fibronectin 82735 Assay of fluoride 82742 Assay of flurazepam (code deleted 1/1/15) 82747 Assay of folic acid, rbc 82757 Assay of semen fructose 82759 Assay of rbc galactokinase 82760 Assay of galactose 82775 Assay galactose transferase 82776 Galactose transferase test 82784 Assay of gammaglobulin igm 82785 Assay of gammaglobulin ige 82787 Igg 1, 2, 3 or 4, each 82800 Blood pH 82803 Blood gases: pH, pO2 & pCO2 82805 Blood gases w/o2 saturation 82810 Blood gases, O2 sat only 82820 Hemoglobin-oxygen affinity 82930 Gastric acid analysis, includes pH if performed, each specimen 82938 Gastrin test 82941 Assay of gastrin 82943 Assay of glucagon 82945 Glucose other fluid 82946 Glucagon tolerance test 82951 Glucose tolerance test (GTT) 82952 GTT-added samples 82953 Glucose-tolbutamide test (code deleted 1/1/15) 82955 Assay of g6pd enzyme 82960 Test for G6PD enzyme 82963 Assay of glucosidase 82965 Assay of gdh enzyme 82975 Assay of glutamine (code deleted 1/1/15) 82978 Assay of glutathione 82979 Assay, rbc glutathione 82980 Assay of glutethimide (code deleted 1/1/15) 82985 Glycated protein 83003 Assay, growth hormone (hgh) 83008 Assay of guanosine (code deleted 1/1/15) 83009 H pylori (c-13), blood 83010 Assay of haptoglobin, quant 83012 Assay of haptoglobins 83014 H pylori drug admin 83015 Heavy metal screen 83018 Quantitative screen, metals 83020 Hemoglobin electrophoresis 83021 Hemoglobin chromotography 83026 Hemoglobin, copper sulfate 83030 Fetal hemoglobin, chemical 83033 Fetal hemoglobin assay, qual 83037 Glycosylated hb, home device 83045 Blood methemoglobin test 83050 Blood methemoglobin assay 83051 Assay of plasma hemoglobin 83055 Blood sulfhemoglobin test (code deleted 1/1/15) 83060 Blood sulfhemoglobin assay 83065 Assay of hemoglobin heat 83068 Hemoglobin stability screen 83069 Assay of urine hemoglobin 83070 Assay of hemosiderin, qual 83071 Assay of hemosiderin, quant (code deleted 1/1/15) 83080 Assay of b hexosaminidase 83088 Assay of histamine 83090 Assay of homocystine 83150 Assay of for hva 83491 Assay of corticosteroids 83497 Assay of 5-hiaa 83500 Assay, free hydroxyproline 83505 Assay, total hydroxyproline 83516 Immunoassay, nonantibody 83518 Immunoassay, dipstick 83519 Immunoassay, nonantibody 83520 Immunoassay, RIA 83525 Assay of insulin 83527 Assay of insulin 83528 Assay of intrinsic factor 83570 Assay of idh enzyme 83582 Assay of ketogenic steroids 83586 Assay 17- ketosteroids 83593 Fractionation, ketosteroids 83605 Assay of lactic acid 83625 Assay of ldh enzymes 83630 Lactoferrin, fecal (qual) 83631 Lactoferrin, fecal (quant) 83632 Placental lactogen 83633 Test urine for lactose 83634 Assay of urine for lactose (code deleted 1/1/15) 83661 L/s ratio, fetal lung 83662 Foam stability, fetal lung 83663 Fluoro polarize, fetal lung 83664 Lamellar bdy, fetal lung 83670 Assay of lap enzyme 83690 Assay of lipase 83695 Assay of lipoprotein(a) 83698 Assay lipoprotein pla2 83700 Lipopro bld, electrophoretic 83701 Lipoprotein bld, hr fraction 83704 Lipoprotein, bld, by nmr 83727 Assay of lrh hormone 83775 Assay of md enzyme 83785 Assay of manganese 83788 Mass spectrometry qual (code deleted 1/1/16) 83789 Mass spectrometry quant 83805 Assay of meprobamate (code deleted 1/1/15) 83825 Assay of mercury 83835 Assay of metanephrines 83840 Assay of methadone (code deleted 1/1/15) 83857 Assay of methemalbumin 83858 Assay of methsuximide (code deleted 1/1/15) 83864 Mucopolysaccharides 83866 Mucopolysaccharides screen (code deleted 1/1/15) 83872 Assay synovial fluid mucin 83873 Assay of csf protein 83874 Assay of myoglobin 83880 Natriuretic peptide 83883 Assay, nephelometry not spec 83885 Assay of nickel 83887 Assay of nicotine (code deleted 1/1/15) 83916 Oligoclonal bands 83918 Organic acids, total, quant 83919 Organic acids, qual, each 83921 Organic acid, single, quant 83925 Assay of opiates (code deleted 1/1/15) 83930 Assay of blood osmolality 83935 Assay of urine osmolality 83937 Assay of osteocalcin 83945 Assay of oxalate 83950 Oncoprotein, her-2/neu 83970 Assay of parathormone 83986 Assay of body fluid acidity 83992 Assay for phencyclidine 83993 Assay for calprotectin fecal 84022 Assay of phenothiazine (code deleted 1/1/15) 84035 Assay of phenylketones 84060 Assay acid phosphatase 84061 Phosphatase, forensic exam 84066 Assay prostate phosphatase 84078 Assay alkaline phosphatase 84080 Assay alkaline phosphatases 84081 Amniotic fluid enzyme test 84085 Assay of rbc pg6d enzyme 84087 Assay phosphohexose enzymes 84105 Assay of urine phosphorus 84106 Test for porphobilinogen 84110 Assay of porphobilinogen 84119 Test urine for porphyrins 84120 Assay of urine porphyrins 84126 Assay of feces porphyrins 84127 Assay of feces porphyrins (code deleted 1/1/15) 84132 Assay of serum potassium 84133 Assay of urine potassium 84134 Assay of prealbumin 84135 Assay of pregnanediol 84138 Assay of pregnanetriol 84140 Assay of pregnenolone 84143 Assay of 17-hydroxypregneno 84146 Assay of Prolactin 84150 Assay of prostaglandin 84157 Assay of protein, other 84160 Assay of protein, any source 84163 Pappa, serum 84165 Protein e-phoresis, serum 84166 Protein e-phoresis/urine/csf 84181 Western blot test 84182 Protein, western blot test 84202 Assay RBC protoporphyrin 84203 Test RBC protoporphyrin 84206 Assay of proinsulin 84207 Assay of vitamin b-6 84210 Assay of pyruvate 84220 Assay of pyruvate kinase 84228 Assay of quinine 84235 Assay of endocrine hormone 84238 Assay, nonendocrine receptor 84244 Assay of renin 84252 Assay of vitamin b-2 84255 Assay of selenium 84260 Assay of serotonin 84270 Assay of sex hormone globul 84275 Assay of sialic acid 84285 Assay of silica 84302 Assay of sweat sodium 84305 Assay of somatomedin 84307 Assay of somatostatin 84311 Spectrophotometry 84315 Body fluid specific gravity 84375 Chromatogram assay, sugars 84376 Sugars, single, qual 84377 Sugars, multiple, qual 84378 Sugars, single, quant 84379 Sugars multiple quant 84392 Assay of urine sulfate 84425 Assay of vitamin b-1 84430 Assay of thiocyanate 84445 Assay of tsi 84446 Assay of vitamin e 84449 Assay of transcortin 84484 Assay of troponin, quant 84485 Assay duodenal fluid trypsin 84488 Test feces for trypsin 84490 Assay of feces for trypsin 84510 Assay of tyrosine 84512 Assay of troponin, qual 84545 Urea-N clearance test 84560 Assay of urine/uric acid 84577 Assay of feces/urobilinogen 84578 Test urine urobilinogen 84580 Assay of urine urobilinogen 84583 Assay of urine urobilinogen 84585 Assay of urine vma 84586 Assay of vip 84588 Assay of vasopressin 84590 Assay of vitamin a 84591 Assay of nos vitamin 84597 Assay of vitamin k 84600 Assay of volatiles 84620 Xylose tolerance test 84630 Assay of zinc 84681 Assay of c-peptide 84702 Chorionic gonadotropin test 84703 Chorionic gonadotropin assay 84704 Hcg, free betachain test 84830 Ovulation tests 84999 Clinical chemistry test 85002 Bleeding time test 85060 Blood smear interpretation 85097 Bone marrow interpretation 85130 Chromogenic substrate assay 85170 Blood clot retraction 85175 Blood clot lysis time 85210 Blood clot factor II test 85220 Blood clot factor V test 85230 Blood clot factor VII test 85240 Blood clot factor VIII test 85244 Blood clot factor VIII test 85245 Blood clot factor VIII test 85246 Blood clot factor VIII test 85247 Blood clot factor VIII test 85250 Blood clot factor IX test 85260 Blood clot factor X test 85270 Blood clot factor XI test 85280 Blood clot factor XII test 85290 Blood clot factor XIII test 85291 Blood clot factor XIII test 85292 Blood clot factor assay 85293 Blood clot factor assay 85300 Antithrombin III test 85301 Antithrombin III test 85302 Blood clot inhibitor antigen 85303 Blood clot inhibitor test 85305 Blood clot inhibitor assay 85306 Blood clot inhibitor test 85307 Assay activated protein c 85335 Factor inhibitor test 85337 Thrombomodulin 85345 Coagulation time 85347 Coagulation time 85348 Coagulation time 85360 Euglobulin lysis 85362 Fibrin degradation products 85366 Fibrinogen test 85370 Fibrinogen test 85378 Fibrin degrade, semiquant 85379 Fibrin degradation, quant 85380 Fibrin degradation, vte 85384 Fibrinogen 85385 Fibrinogen 85390 Fibrinolysins screen 85396 Clotting assay, whole blood 85400 Fibrinolytic plasmin 85410 Fibrinolytic antiplasmin 85415 Fibrinolytic plasminogen 85420 Fibrinolytic plasminogen 85421 Fibrinolytic plasminogen 85441 Heinz bodies, direct 85445 Heinz bodies, induced 85460 Hemoglobin, fetal 85461 Hemoglobin, fetal 85475 Hemolysin 85520 Heparin assay 85525 Heparin neutralization 85530 Heparin-protamine tolerance 85536 Iron stain peripheral blood 85540 Wbc alkaline phosphatase 85547 RBC mechanical fragility 85549 Muramidase 85555 RBC osmotic fragility 85557 RBC osmotic fragility 85576 Blood platelet aggregation 85597 Platelet neutralization 85612 Viper venom prothrombin time 85613 Russell viper venom, diluted 85635 Reptilase test 85670 Thrombin time, plasma 85675 Thrombin time, titer 85705 Thromboplastin inhibition 85730 Thromboplastin time, partial 85732 Thromboplastin time, partial 85810 Blood viscosity examination 85999 Hematology procedure 86000 Agglutinins, febrile 86021 WBC antibody identification 86022 Platelet antibodies 86023 Immunoglobulin assay 86038 Antinuclear antibodies 86039 Antinuclear antibodies (ANA) 86060 Antistreptolysin o, titer 86063 Antistreptolysin o, screen 86141 C-reactive protein, hs 86146 Glycoprotein antibody 86147 Cardiolipin antibody 86148 Phospholipid antibody 86155 Chemotaxis assay 86156 Cold agglutinin, screen 86157 Cold agglutinin, titer 86160 Complement, antigen 86161 Complement/function activity 86162 Complement, total (CH50) 86171 Complement fixation, each 86185 Counterimmunoelectrophoresis 86200 Ccp antibody 86215 Deoxyribonuclease, antibody 86225 DNA antibody 86226 DNA antibody, single strand 86235 Nuclear antigen antibody 86243 Fc receptor 86255 Fluorescent antibody, screen 86256 Fluorescent antibody, titer 86277 Growth hormone antibody 86280 Hemagglutination inhibition 86294 Immunoassay, tumor, qual 86300 Immunoassay, tumor, ca 15-3 86301 Immunoassay, tumor, ca 19-9 86304 Immunoassay, tumor, ca 125 86308 Heterophile antibodies 86309 Heterophile antibodies 86310 Heterophile antibodies 86316 Immunoassay, tumor other 86317 Immunoassay,infectious agent 86318 Immunoassay,infectious agent 86320 Serum immunoelectrophoresis 86325 Other immunoelectrophoresis 86327 Immunoelectrophoresis assay 86329 Immunodiffusion 86331 Immunodiffusion ouchterlony 86332 Immune complex assay 86334 Immunofix e-phoresis, serum 86335 Immunfix e-phorsis/urine/csf 86336 Inhibin A 86337 Insulin antibodies 86340 Intrinsic factor antibody 86341 Islet cell antibody 86343 Leukocyte histamine release 86344 Leukocyte phagocytosis 86353 Lymphocyte transformation 86355 B cells, total count 86356 Mononuclear cell antigen 86357 Nk cells, total count 86359 T cells, total count 86360 T cell, absolute count/ratio 86361 T cell, absolute count 86367 Stem cells, total count 86376 Microsomal antibody 86378 Migration inhibitory factor 86382 Neutralization test, viral 86384 Nitroblue tetrazolium dye 86403 Particle agglutination test 86406 Particle agglutination test 86430 Rheumatoid factor test 86431 Rheumatoid factor, quant 86480 Tb test, cell immun measure 86485 Skin test, candida 86486 Skin test, nos antigen 86490 Coccidioidomycosis skin test 86510 Histoplasmosis skin test 86590 Streptokinase, antibody 86592 Blood serology, qualitative 86593 Blood serology, quantitative 86602 Antinomyces antibody 86603 Adenovirus antibody 86606 Aspergillus antibody 86609 Bacterium antibody 86611 Bartonella antibody 86612 Blastomyces antibody 86615 Bordetella antibody 86617 Lyme disease antibody 86618 Lyme disease antibody 86619 Borrelia antibody 86622 Brucella antibody 86625 Campylobacter antibody 86628 Candida antibody 86631 Chlamydia antibody 86632 Chlamydia igm antibody 86635 Coccidioides antibody 86638 Q fever antibody 86641 Cryptococcus antibody 86644 CMV antibody 86645 CMV antibody, IgM 86648 Diphtheria antibody 86651 Encephalitis antibody 86652 Encephalitis antibody 86653 Encephalitis antibody 86654 Encephalitis antibody 86658 Enterovirus antibody 86663 Epstein-barr antibody 86664 Epstein-barr antibody 86665 Epstein-barr antibody 86666 Ehrlichia antibody 86668 Francisella tularensis 86671 Fungus antibody 86674 Giardia lamblia antibody 86677 Helicobacter pylori 86682 Helminth antibody 86684 Hemophilus influenza 86687 Htlv-i antibody 86688 Htlv-ii antibody 86689 HTLV/HIV confirmatory test 86692 Hepatitis, delta agent 86694 Herpes simplex test 86695 Herpes simplex test 86696 Herpes simplex type 2 86698 Histoplasma 86701 HIV-1 86702 HIV-2 86703 HIV-1/HIV-2, single assay 86704 Hep b core antibody, total 86705 Hep b core antibody, igm 86706 Hep b surface antibody 86707 Hep be antibody 86708 Hep A antibody, total 86709 Hep A antibody, igm 86710 Influenza virus antibody 86713 Legionella antibody 86717 Leishmania antibody 86720 Leptospira antibody 86723 Listeria monocytogenes ab 86727 Lymph choriomeningitis ab 86729 Lympho venereum antibody 86732 Mucormycosis antibody 86735 Mumps antibody 86738 Mycoplasma antibody 86741 Neisseria meningitidis 86744 Nocardia antibody 86747 Parvovirus antibody 86750 Malaria antibody 86753 Protozoa antibody nos 86756 Respiratory virus antibody 86757 Rickettsia antibody 86759 Rotavirus antibody 86762 Rubella antibody 86765 Rubeola antibody 86768 Salmonella antibody 86771 Shigella antibody 86774 Tetanus antibody 86777 Toxoplasma antibody 86778 Toxoplasma antibody, igm 86780 Treponema Pallidum 86784 Trichinella antibody 86787 Varicella-zoster antibody 86788 West Nile virus ab, igm 86789 West Nile virus antibody 86790 Virus antibody nos 86793 Yersinia antibody 86800 Thyroglobulin antibody 86803 Hepatitis c ab test 86804 Hep c ab test, confirm 86805 Lymphocytotoxicity assay 86806 Lymphocytotoxicity assay 86807 Cytotoxic antibody screening 86808 Cytotoxic antibody screening 86812 HLA typing, A, B, or C 86813 HLA typing, A, B, or C 86816 HLA typing, DR/DQ 86817 HLA typing, DR/DQ 86821 Lymphocyte culture, mixed 86822 Lymphocyte culture, primed 86849 Immunology procedure 86850 RBC antibody screen 86860 RBC antibody elution 86870 RBC antibody identification 86880 Coombs test, direct 86885 Coombs test, indirect, qual 86886 Coombs test, indirect, titer 86890 Autologous blood process 86891 Autologous blood, op salvage 86900 Blood typing, ABO 86901 Blood typing, Rh (D) 86902 Blood Typing, Serologic; antigen testing of donor blood using reagent serum, each antigen test 86904 Blood typing, patient serum 86905 Blood typing, RBC antigens 86906 Blood typing, Rh phenotype 86911 Blood typing, antigen system 86920 Compatibility test, spin 86921 Compatibility test, incubate 86922 Compatibility test, antiglob 86923 Compatibility test, electric 86940 Hemolysins/agglutinins, auto 86941 Hemolysins/agglutinins 87001 Small animal inoculation (code deleted 1/1/15) 87003 Small animal inoculation 87015 Specimen concentration 87040 Blood culture for bacteria 87045 Feces culture, bacteria 87046 Stool cultr, bacteria, each 87070 Culture, bacteria, other 87071 Culture bacteria aerobic other 87073 Culture bacteria anaerobic 87075 Cultr bacteria, except blood 87076 Culture anaerobe ident, each 87077 Culture aerobic identify 87081 Culture screen only 87084 Culture of specimen by kit 87086 Urine culture/colony count 87088 Urine bacteria culture 87101 Skin fungi culture 87102 Fungus isolation culture 87103 Blood fungus culture 87106 Fungi identification, yeast 87107 Fungi identification, mold 87109 Mycoplasma 87110 Chlamydia culture 87116 Mycobacteria culture 87118 Mycobacteria identification 87140 Culture type immunofluoresc 87143 Culture typing, glc/hplc 87147 Culture type, immunologic 87149 Culture type, nucleic acid 87152 Culture type pulse field gel 87158 Culture typing, added method 87164 Dark field examination 87166 Dark field examination 87168 Macroscopic exam arthropod 87169 Macroscopic exam parasite 87172 Pinworm exam 87176 Tissue homogenization, cultr 87177 Ova and parasites smears 87181 Microbe susceptible, diffuse 87184 Microbe susceptible, disk 87185 Microbe susceptible, enzyme 87186 Microbe susceptible, mic 87187 Microbe susceptible, mlc 87188 Microbe suscept, macrobroth 87190 Microbe suscept, mycobacteri 87197 Bactericidal level, serum 87205 Smear, gram stain 87206 Smear, fluorescent/acid stain 87207 Smear, special stain 87209 Smear, complex stain 87220 Tissue exam for fungi 87230 Assay, toxin or antitoxin 87250 Virus inoculate, eggs/animal 87252 Virus inoculation, tissue 87253 Virus inoculate tissue, addl 87254 Virus inoculation, shell via 87255 Genet virus isolate, hsv 87260 Adenovirus ag, if 87265 Pertussis ag, if 87267 Enterovirus antibody, dfa 87269 Giardia ag, if 87270 Chlamydia trachomatis ag, if 87271 Cytomegalovirus dfa 87272 Cryptosporidium ag, if 87273 Herpes simplex 2, ag, if 87274 Herpes simplex 1, ag, if 87275 Influenza b, ag, if 87276 Influenza a, ag, if 87277 Legionella micdadei, ag, if 87278 Legion pneumophilia ag, if 87279 Parainfluenza, ag, if 87280 Respiratory syncytial ag, if 87281 Pneumocystis carinii, ag, if 87283 Rubeola, ag, if 87285 Treponema pallidum, ag, if 87290 Varicella zoster, ag, if 87299 Antibody detection, nos, if 87300 Ag detection, polyval, if 87301 Adenovirus ag, eia 87305 Aspergillus ag, eia 87320 Chylmd trach ag, eia 87324 Clostridium ag, eia 87327 Cryptococcus neoform ag, eia 87328 Cryptosporidium ag, eia 87329 Giardia ag, eia 87332 Cytomegalovirus ag, eia 87335 E coli 0157 ag, eia 87336 Entamoeb hist dispr, ag, eia 87337 Entamoeb hist group, ag, eia 87338 Hpylori, stool, eia 87339 H pylori ag, eia 87340 Hepatitis b surface ag, eia 87341 Hepatitis b surface, ag, eia 87350 Hepatitis be ag, eia 87380 Hepatitis delta ag, eia 87385 Histoplasma capsule ag, eia 87390 Hiv-1 ag, eia 87391 Hiv-2 ag, eia 87400 Influenza a/b, ag, eia 87420 Resp syncytial ag, eia 87425 Rotavirus ag, eia 87427 Shiga-like toxin ag, eia 87449 Ag detect nos, eia, mult 87450 Ag detect nos, eia, single 87451 Ag detect polyval, eia, mult 87470 Bartonella, dna, dir probe 87471 Bartonella, dna, amp probe 87472 Bartonella, dna, quant 87475 Lyme dis, dna, dir probe 87476 Lyme dis, dna, amp probe 87477 Lyme dis, dna, quant 87480 Candida, dna, dir probe 87481 Candida, dna, amp probe 87482 Candida, dna, quant 87485 Chylmd pneum, dna, dir probe 87486 Chylmd pneum, dna, amp probe 87487 Chylmd pneum, dna, quant 87490 Chylmd trach, dna, dir probe 87491 Chylmd trach, dna, amp probe 87492 Chylmd trach, dna, quant 87495 Cytomeg, dna, dir probe 87496 Cytomeg, dna, amp probe 87497 Cytomeg, dna, quant 87498 Enterovirus, dna, amp probe 87500 Vancomycin, dna, amp probe 87505 Gastrointestinal pathogen, includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3 - 5 targets 87506 Gastrointestinal pathogen, includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 6 - 11 targets 87507 Gastrointestinal pathogen, includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 12 - 25 targets 87510 Gardner vag, dna, dir probe 87511 Gardner vag, dna, amp probe 87512 Gardner vag, dna, quant 87515 Hepatitis b, dna, dir probe 87516 Hepatitis b, dna, amp probe 87517 Hepatitis b, dna, quant 87520 Hepatitis c, rna, dir probe 87521 Hepatitis c, rna, amp probe 87522 Hepatitis c, rna, quant 87525 Hepatitis g, dna, dir probe 87526 Hepatitis g, dna, amp probe 87527 Hepatitis g, dna, quant 87528 Hsv, dna, dir probe 87529 Hsv, dna, amp probe 87530 Hsv, dna, quant 87531 Hhv-6, dna, dir probe 87532 Hhv-6, dna, amp probe 87533 Hhv-6, dna, quant 87534 Hiv-1, dna, dir probe 87535 Hiv-1, dna, amp probe 87536 Hiv-1, dna, quant 87537 Hiv-2, dna, dir probe 87538 Hiv-2, dna, amp probe 87539 Hiv-2, dna, quant 87540 Legion pneumo, dna, dir prob 87541 Legion pneumo, dna, amp prob 87542 Legion pneumo, dna, quant 87550 Mycobacteria, dna, dir probe 87551 Mycobacteria, dna, amp probe 87552 Mycobacteria, dna, quant 87555 M.tuberculo, dna, dir probe 87556 M.tuberculo, dna, amp probe 87557 M.tuberculo, dna, quant 87560 M.avium-intra, dna, dir prob 87561 M.avium-intra, dna, amp prob 87562 M.avium-intra, dna, quant 87580 M.pneumon, dna, dir probe 87581 M.pneumon, dna, amp probe 87582 M.pneumon, dna, quant 87590 N.gonorrhoeae, dna, dir prob 87591 N.gonorrhoeae, dna, amp prob 87592 N.gonorrhoeae, dna, quant 87620 Hpv, dna, dir probe (code deleted 1/1/15) 87621 Hpv, dna, amp probe (code deleted 1/1/15) 87622 Hpv, dna, quant (code deleted 1/1/15) 87623 Human Papillomavirus (HPV), low risk types (e.g., 6, 11, 42, 43, 44) 87624 Human Papillomavirus (HPV), high risk types (e.g., 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) 87625 Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed 87640 Staph a, dna, amp probe 87641 Mr-staph, dna, amp probe 87650 Strep a, dna, dir probe 87651 Strep a, dna, amp probe 87652 Strep a, dna, quant 87653 Strep b, dna, amp probe 87660 Trichomonas vagin, dir probe 87797 Detect agent nos, dna, dir 87798 Detect agent nos, dna, amp 87799 Detect agent nos, dna, quant 87800 Detect agnt mult, dna, direc 87801 Detect agnt mult, dna, ampli 87802 Strep b assay w/optic 87803 Clostridium toxin a w/optic 87806 Infectious agent antigen detection by immunoassay with direct optical observation; HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies 87807 Rsv assay w/optic 87808 Trichomonas assay w/optic 87809 Adenovirus assay w/optic 87899 Agent nos assay w/optic 87900 Phenotype, infect agent drug 87901 Genotype, dna, hiv reverse t 87902 Genotype, dna, hepatitis C 87903 Phenotype, dna hiv w/culture 87904 Phenotype, dna hiv w/clt add 87999 Microbiology procedure 88104 Cytopath fl nongyn, smears 88106 Cytopath fl nongyn, filter 88108 Cytopath, concentrate tech 88112 Cytopath, cell enhance tech 88130 Sex chromatin identification 88140 Sex chromatin identification 88141 Cytopath, c/v, interpret 88142 Cytopath, c/v, thin layer 88143 Cytopath c/v thin layer redo 88147 Cytopath, c/v, automated 88148 Cytopath, c/v, auto rescreen 88150 Cytopath, c/v, manual 88152 Cytopath, c/v, auto redo 88153 Cytopath, c/v, redo 88154 Cytopath, c/v, select 88155 Cytopath, c/v, index add-on 88160 Cytopath smear, other source 88161 Cytopath smear, other source 88162 Cytopath smear, other source 88164 Cytopath tbs, c/v, manual 88165 Cytopath tbs, c/v, redo 88166 Cytopath tbs, c/v, auto redo 88167 Cytopath tbs, c/v, select 88172 Cytopathology eval of fna 88173 Cytopath eval, fna, report 88174 Cytopath, c/v auto, in fluid 88175 Cytopath c/v auto fluid redo 88182 Cell marker study 88184 Flowcytometry/ tc, 1 marker 88185 Flowcytometry/tc, add-on 88187 Flowcytometry/read, 2-8 88188 Flowcytometry/read, 9-15 88189 Flowcytometry/read, 16 & > 88199 Cytopathology procedure 88300 Surgical path, gross 88302 Tissue exam by pathologist 88304 Tissue exam by pathologist 88305 Tissue exam by pathologist 88307 Tissue exam by pathologist 88309 Tissue exam by pathologist 88311 Decalcify tissue 88312 Special stains 88313 Special stains 88314 Histochemical stain 88319 Enzyme histochemistry 88321 Microslide consultation 88323 Microslide consultation 88325 Comprehensive review of data 88329 Path consult intraop 88331 Path consult intraop, 1 bloc 88332 Path consult intraop, addÆl 88333 Intraop cyto path consult, 1 88334 Intraop cyto path consult, 2 88342 Immunohistochemistry 88346 Immunofluorescent study 88347 Immunofluorescent study (code deleted 1/1/16) 88355 Analysis, skeletal muscle 88356 Analysis, nerve 88358 Analysis, tumor 88360 Tumor immunohistochem/manual 88361 Tumor immunohistochem/comput 88362 Nerve teasing preparations 88371 Protein, western blot tissue 88372 Protein analysis w/probe 88380 Microdissection, laser 88381 Microdissection, manual 88399 Surgical pathology procedure 88720 Bilirubin, total, transcutaneous 89049 Chct for mal hyperthermia 89050 Body fluid cell count 89051 Body fluid cell count 89055 Leukocyte assessment, fecal 89060 Exam, synovial fluid crystals 89125 Specimen fat stain 89160 Exam feces for meat fibers 89190 Nasal smear for eosinophils 89220 Sputum specimen collection 89230 Collect sweat for test 89240 Pathology lab procedure 89310 Semen analysis w/count 89320 Semen anal vol/count/mot 90281 Human ig, im 90283 Human ig, iv 90371 Hep b ig, im 90375 Rabies ig, im/sc 90378 Respiratory syncytial virus, monoclonal antibody, recombinant, IM, 50 mg, ea 90384 Rh ig, full-dose, im 90385 Rh ig, minidose, im 90386 Rh ig, iv 90389 Tetanus ig, im 90396 Varicella-zoster ig, im 90399 Immune globulin 90585 Bcg vaccine, percut 90586 Bcg vaccine, intravesical 90675 Rabies vaccine, im 90717 Yellow fever vaccine, sc 90735 Encephalitis vaccine, sc (code deleted 1/1/16) 92358 Prosthesis service for aphakia, temporary (disposable or loan, including materials) 92532 Positional nystagmus test 92533 Caloric vestibular test, each irrigation (binaural, bithermal stimulation constitutes four tests) 92534 Optokinetic nystagmus test 92541 Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording 92542 Positional nystagmus test, minimum of 4 positions, with recording 92543 Caloric vestibular test, each irrigation (binaural, bithermal stimulation constitutes four tests), with recording (code deleted 1/1/16) 92544 Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, w/recording 92545 Oscillating tracking test, with recording 92546 Sinusoidal vertical axis rotational testing 92547 Use of vertical electrodes (List separately in addition to code for primary procedure) 92559 Audiometric testing of groups 93050 Arterial pressure waveform analysis for assessment of central arterial pressures (new code 1/1/16) 93279 Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional; single lead pacemaker system 93280 Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional; dual lead pacemaker system 93282 Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional; single lead transvenous implantable defibrillator system 93283 Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional; dual lead transvenous implantable defibrillator system 93288 Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection, per patient encounter; single, dial, or multiple lead pacemaker system 93289 Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection, per patient encounter; single, dial, or multiple lead transvenous implantable defibrillator system, including analysis of heart rhythm derived data elements 93292 Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection, per patient encounter; wearable defibrillator system 93293 Transtelephonic rhythm strip pacemaker evaluation(s) single, dual, or multiple lead pacemaker system, includes recording with and without magnet application with analysis, review and report(s) by a physician or other qualified health care professional, up to 90 days 93294 Interrogation device evaluation(s) (remote), up to 90 days; single, dual, or multiple lead pacemaker system with interim analysis, review(s) and report(s) by a physician or other qualified health care professional 93295 Interrogation device evaluation(s) (remote), up to 90 days; single, dual, or multiple lead implantable defibrillator system with interim analysis, review(s) and report(s) by a physician or other qualified health care professional 93740 Temperature gradient studies 93784 Ambulatory blood pressure monitoring, utilizing a system such as magnetic tape and / or computer disk, for 24 hours or longer; including recording, scanning analysis, interpretation and report 93786 Ambulatory blood pressure monitoring, utilizing a system such as magnetic tape and / or computer disk, for 24 hours or longer; recording only 93788 Ambulatory blood pressure monitoring, utilizing a system such as magnetic tape and / or computer disk, for 24 hours or longer; scanning analysis with report 93790 Ambulatory blood pressure monitoring, utilizing a system such as magnetic tape and / or computer disk, for 24 hours or longer; physician review with interpretation and report 94060 Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration 94070 Bronchospasm provocation evaluation, multiple spirometric determinations as in 94010, with administered agents (e.g., antigen(s), cold air, methacholine) 94250 Expired gas collection, quantitative, single procedure (separate procedure) 94375 Respiratory flow volume loop 94640 Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes (e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing [IPPB] device) 94644 Continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour 94645 Continuous inhalation treatment with aerosol medication for acute airway obstruction; each additional hour (List separately in addition to code for primary procedure) 94664 Demonstration and / or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device 94726 Plethysmography for determination of lung volumes and, when performed, airway resistance 94727 Gas dilution or washout for determination of lung volumes and, when performed, distribution of ventilation and closing volumes 94728 Airway resistance by impulse oscillometry 94761 Noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations (e.g., during exercise) 95831 Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk 95832 Muscle testing, manual (separate procedure) with report; hand, with or without comparison with normal side 95833 Muscle testing, manual (separate procedure) with report; total evaluation of body, excluding hands 95834 Muscle testing, manual (separate procedure) with report; total evaluation of body, including hands 95851 Range of motion measurements and report (separate procedure); each extremity (excluding hand) or each trunk section (spine) 95852 Range of motion measurements and report (separate procedure); hand, with or without comparison with normal side 96360 Intravenous infusion, hydration; initial, 31 minutes to 1 hour 96361 Intravenous infusion, hydration; each additional hour (add-on code) 96373 Therapeutic, prophylactic, or diagnostic injection; Intra-arterial 96374 Therapeutic, prophylactic, or diagnostic injection; IV push, single or initial substance/drug 96375 Therapeutic, prophylactic, or diagnostic injection; each additional sequential IV push of a new substance/drug (add-on code) 96523 Irrigation of implanted venous access device for drug delivery systems 96567 Photodynamic therapy by external application of light to destroy premalignant and / or malignant lesions of the skin and adjacent mucosa (e.g., lip) by activation of photosensitive drug(s), each phototherapy exposure session 96900 Actinotherapy (ultraviolet light) 96902 Microscopic examination of hairs plucked or clipped by the examiner (excluding hair collected by the patient) to determine telogen and anagen counts, or structural hair shaft abnormality 96904 Whole body integumentary photography, for monitoring of high risk patients with dysplastic nevus syndrome or a history of dysplastic nevi, or patients with a personal or familial history of melanoma 96910 Photochemotherapy; tar and ultraviolet B (Goeckerman treatment) or petrolatum and ultraviolet B 96912 Photochemotherapy; psoralens and ultraviolet A (PUVA) 97597 Debridement, open wound, including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq. cm or less 97598 Debridement, open wound, including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; each additional 20 sq. cm, or part thereof (add-on code) 99170 Anogenital examination with colposcopic magnification in childhood for suspected trauma 99175 Ipecac or similar administration for individual emesis and continued observation until stomach adequately emptied of poison 99195 Phlebotomy, therapeutic (separate procedure)
Limits
All other coverage exclusions, limitations, restrictions, preauthorization requirements and other rules continue to apply.
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.

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