code
stringlengths 4
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stringclasses 8
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|---|---|---|---|
D0330
|
PR PANORAMIC RADIOGRAPHIC IMAGE
|
HCPCS
|
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy.
|
70328
|
XR TMJ UNILATERAL
|
HCPCS
|
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy.
|
D2999
|
PR UNSPEC RESTORATIVE PROC BY REPORT
|
HCPCS
|
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy.
|
D0230
|
PR IO-PERIAPICAL EA ADD RADIOGRPH IMAG
|
HCPCS
|
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy.
|
21240
|
Reconstruction of jaw joint
|
HCPCS
|
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy.
|
70332
|
X-ray exam of jaw joint
|
HCPCS
|
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy.
|
21243
|
Reconstruction of jaw joint
|
HCPCS
|
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy.
|
D1510
|
Space maintainer fxd unilat
|
HCPCS
|
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy.
|
70250
|
XR Skull < 4 Views
|
HCPCS
|
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy.
|
D1550
|
Recement space maintainer
|
HCPCS
|
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy.
|
95867
|
PR NEEDLE ELECTROMYOGRAPHY CRANIAL NRV MUSCLE UNI
|
HCPCS
|
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy.
|
D2940
|
PR PROTECTIVE RESTORATION
|
HCPCS
|
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy.
|
D5899
|
Removable prosthodontic proc
|
HCPCS
|
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy.
|
70260
|
XR SKULL 4 VIEWS
|
HCPCS
|
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy.
|
95868
|
PR NEEDLE ELECTROMYOGRAPHY CRANIAL NRV MUSCLE BI
|
HCPCS
|
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy.
|
D0210
|
PR INTRAORAL-CMPL SER RADIOGRAPH IMAGS
|
HCPCS
|
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy.
|
D7873
|
Tmj arthroscopy lysis adhesn
|
HCPCS
|
This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered.
|
96000
|
PR COMPRE CPTR MTN ALYS VIDEO TAPING 3D KINEMATICS
|
HCPCS
|
This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered.
|
70320
|
Full mouth x-ray of teeth
|
HCPCS
|
This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered.
|
93762
|
Peripheral Thermogram
|
HCPCS
|
This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered.
|
D7877
|
Tmj arthroscopy debridement
|
HCPCS
|
This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered.
|
96004
|
PR PHYS/QHP R&I CPTR MTN ALYS WALK/FUNCJL ACTV REPR
|
HCPCS
|
This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered.
|
70310
|
X-ray exam of teeth
|
HCPCS
|
This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered.
|
70300
|
X-ray exam of teeth
|
HCPCS
|
This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered.
|
S8262
|
MANDIB ORTHO REPOSITION DEVICE EACH
|
CPT
|
This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered.
|
93760
|
Cephalic Thermogram
|
HCPCS
|
This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered.
|
D8999
|
PR UNS ORTHODONTIC PROCEDURE BY REPORT
|
HCPCS
|
This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered.
|
D8010
|
PR LTD ORTHODONT TX PRIMARY DENTITION
|
HCPCS
|
This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered.
|
D0330
|
PR PANORAMIC RADIOGRAPHIC IMAGE
|
HCPCS
|
This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered.
|
70328
|
XR TMJ UNILATERAL
|
HCPCS
|
This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered.
|
D2999
|
PR UNSPEC RESTORATIVE PROC BY REPORT
|
HCPCS
|
This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered.
|
D0230
|
PR IO-PERIAPICAL EA ADD RADIOGRPH IMAG
|
HCPCS
|
This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered.
|
21240
|
Reconstruction of jaw joint
|
HCPCS
|
This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered.
|
70332
|
X-ray exam of jaw joint
|
HCPCS
|
This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered.
|
21243
|
Reconstruction of jaw joint
|
HCPCS
|
This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered.
|
D1510
|
Space maintainer fxd unilat
|
HCPCS
|
This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered.
|
70250
|
XR Skull < 4 Views
|
HCPCS
|
This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered.
|
D1550
|
Recement space maintainer
|
HCPCS
|
This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered.
|
95867
|
PR NEEDLE ELECTROMYOGRAPHY CRANIAL NRV MUSCLE UNI
|
HCPCS
|
This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered.
|
D2940
|
PR PROTECTIVE RESTORATION
|
HCPCS
|
This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered.
|
D5899
|
Removable prosthodontic proc
|
HCPCS
|
This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered.
|
70260
|
XR SKULL 4 VIEWS
|
HCPCS
|
This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered.
|
95868
|
PR NEEDLE ELECTROMYOGRAPHY CRANIAL NRV MUSCLE BI
|
HCPCS
|
This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered.
|
D0210
|
PR INTRAORAL-CMPL SER RADIOGRAPH IMAGS
|
HCPCS
|
This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered.
|
D7873
|
Tmj arthroscopy lysis adhesn
|
HCPCS
|
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered.
|
96000
|
PR COMPRE CPTR MTN ALYS VIDEO TAPING 3D KINEMATICS
|
HCPCS
|
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered.
|
70320
|
Full mouth x-ray of teeth
|
HCPCS
|
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered.
|
93762
|
Peripheral Thermogram
|
HCPCS
|
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered.
|
D7877
|
Tmj arthroscopy debridement
|
HCPCS
|
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered.
|
96004
|
PR PHYS/QHP R&I CPTR MTN ALYS WALK/FUNCJL ACTV REPR
|
HCPCS
|
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered.
|
21070
|
Remove coronoid process
|
HCPCS
|
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered.
|
70310
|
X-ray exam of teeth
|
HCPCS
|
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered.
|
70300
|
X-ray exam of teeth
|
HCPCS
|
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered.
|
93760
|
Cephalic Thermogram
|
HCPCS
|
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered.
|
76101
|
Complex body section x-ray
|
HCPCS
|
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered.
|
D8999
|
PR UNS ORTHODONTIC PROCEDURE BY REPORT
|
HCPCS
|
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered.
|
D8010
|
PR LTD ORTHODONT TX PRIMARY DENTITION
|
HCPCS
|
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered.
|
D0330
|
PR PANORAMIC RADIOGRAPHIC IMAGE
|
HCPCS
|
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered.
|
21110
|
PR APPL INTERDENTAL FIXATION DEVICE NON-FX/DISLC
|
HCPCS
|
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered.
|
70328
|
XR TMJ UNILATERAL
|
HCPCS
|
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered.
|
D2999
|
PR UNSPEC RESTORATIVE PROC BY REPORT
|
HCPCS
|
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered.
|
D0230
|
PR IO-PERIAPICAL EA ADD RADIOGRPH IMAG
|
HCPCS
|
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered.
|
21240
|
Reconstruction of jaw joint
|
HCPCS
|
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered.
|
70332
|
X-ray exam of jaw joint
|
HCPCS
|
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered.
|
21243
|
Reconstruction of jaw joint
|
HCPCS
|
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered.
|
21085
|
PR IMPRESSION & PREPARATION ORAL SURGICAL SPLINT
|
HCPCS
|
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered.
|
D1510
|
Space maintainer fxd unilat
|
HCPCS
|
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered.
|
70250
|
XR Skull < 4 Views
|
HCPCS
|
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered.
|
76102
|
Complex body section x-rays
|
HCPCS
|
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered.
|
D1550
|
Recement space maintainer
|
HCPCS
|
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered.
|
95867
|
PR NEEDLE ELECTROMYOGRAPHY CRANIAL NRV MUSCLE UNI
|
HCPCS
|
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered.
|
D2940
|
PR PROTECTIVE RESTORATION
|
HCPCS
|
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered.
|
D5899
|
Removable prosthodontic proc
|
HCPCS
|
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered.
|
70260
|
XR SKULL 4 VIEWS
|
HCPCS
|
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered.
|
97762
|
C/o for orthotic/prosth use
|
HCPCS
|
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered.
|
95868
|
PR NEEDLE ELECTROMYOGRAPHY CRANIAL NRV MUSCLE BI
|
HCPCS
|
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered.
|
D0210
|
PR INTRAORAL-CMPL SER RADIOGRAPH IMAGS
|
HCPCS
|
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered.
|
97799
|
Unlisted physcl med/rehab px
|
HCPCS
|
CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered. CPT codes 64555-64595, 90875, 90876, 97012, 97110, 97112, 97530, 97799 added to non-covered.
|
90875
|
PR INDIV PSYCHOPHYS BIOFEED TRAIN W/PSYTX 30 MIN
|
HCPCS
|
CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered. CPT codes 64555-64595, 90875, 90876, 97012, 97110, 97112, 97530, 97799 added to non-covered.
|
64555
|
PR PRQ IMPLTJ NEUROSTIMULATOR ELTRD PERIPHERAL NRV
|
HCPCS
|
CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered. CPT codes 64555-64595, 90875, 90876, 97012, 97110, 97112, 97530, 97799 added to non-covered.
|
21070
|
Remove coronoid process
|
HCPCS
|
CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered. CPT codes 64555-64595, 90875, 90876, 97012, 97110, 97112, 97530, 97799 added to non-covered.
|
76101
|
Complex body section x-ray
|
HCPCS
|
CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered. CPT codes 64555-64595, 90875, 90876, 97012, 97110, 97112, 97530, 97799 added to non-covered.
|
97762
|
C/o for orthotic/prosth use
|
HCPCS
|
CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered. CPT codes 64555-64595, 90875, 90876, 97012, 97110, 97112, 97530, 97799 added to non-covered.
|
97012
|
SBT PTA TRACTION, MECHANICAL PER VI
|
HCPCS
|
CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered. CPT codes 64555-64595, 90875, 90876, 97012, 97110, 97112, 97530, 97799 added to non-covered.
|
97110
|
Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes
|
HCPCS
|
CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered. CPT codes 64555-64595, 90875, 90876, 97012, 97110, 97112, 97530, 97799 added to non-covered.
|
97112
|
Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes
|
HCPCS
|
CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered. CPT codes 64555-64595, 90875, 90876, 97012, 97110, 97112, 97530, 97799 added to non-covered.
|
64595
|
Rev/rmv prph sac/gstr npg/r
|
HCPCS
|
CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered. CPT codes 64555-64595, 90875, 90876, 97012, 97110, 97112, 97530, 97799 added to non-covered.
|
97530
|
Therapy procedure using functional activities
|
HCPCS
|
CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered. CPT codes 64555-64595, 90875, 90876, 97012, 97110, 97112, 97530, 97799 added to non-covered.
|
21085
|
PR IMPRESSION & PREPARATION ORAL SURGICAL SPLINT
|
HCPCS
|
CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered. CPT codes 64555-64595, 90875, 90876, 97012, 97110, 97112, 97530, 97799 added to non-covered.
|
21110
|
PR APPL INTERDENTAL FIXATION DEVICE NON-FX/DISLC
|
HCPCS
|
CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered. CPT codes 64555-64595, 90875, 90876, 97012, 97110, 97112, 97530, 97799 added to non-covered.
|
90876
|
PR INDIV PSYCHOPHYS BIOFEED TRAIN W/PSYTX 45 MIN
|
HCPCS
|
CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered. CPT codes 64555-64595, 90875, 90876, 97012, 97110, 97112, 97530, 97799 added to non-covered.
|
76102
|
Complex body section x-rays
|
HCPCS
|
CPT4 2005 & 2006 revisions added to policy. 1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered. CPT codes 64555-64595, 90875, 90876, 97012, 97110, 97112, 97530, 97799 added to non-covered.
|
97799
|
Unlisted physcl med/rehab px
|
HCPCS
|
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered. CPT codes 64555-64595, 90875, 90876, 97012, 97110, 97112, 97530, 97799 added to non-covered. CPT codes 21025-21049, 21141-21147, 21150, 21151, 21193-21196, 21198, 21199, 21244-21255, 21440-21470, 70100, 70110, 70140, 70150, 70250, 70260 removed from covered table.
|
21470
|
Treat lower jaw fracture
|
HCPCS
|
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered. CPT codes 64555-64595, 90875, 90876, 97012, 97110, 97112, 97530, 97799 added to non-covered. CPT codes 21025-21049, 21141-21147, 21150, 21151, 21193-21196, 21198, 21199, 21244-21255, 21440-21470, 70100, 70110, 70140, 70150, 70250, 70260 removed from covered table.
|
1470
|
Anesthesia for procedure lower leg, foot
|
HCPCS
|
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered. CPT codes 64555-64595, 90875, 90876, 97012, 97110, 97112, 97530, 97799 added to non-covered. CPT codes 21025-21049, 21141-21147, 21150, 21151, 21193-21196, 21198, 21199, 21244-21255, 21440-21470, 70100, 70110, 70140, 70150, 70250, 70260 removed from covered table.
|
97112
|
Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes
|
HCPCS
|
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered. CPT codes 64555-64595, 90875, 90876, 97012, 97110, 97112, 97530, 97799 added to non-covered. CPT codes 21025-21049, 21141-21147, 21150, 21151, 21193-21196, 21198, 21199, 21244-21255, 21440-21470, 70100, 70110, 70140, 70150, 70250, 70260 removed from covered table.
|
21198
|
Reconstr lwr jaw segment
|
HCPCS
|
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered. CPT codes 64555-64595, 90875, 90876, 97012, 97110, 97112, 97530, 97799 added to non-covered. CPT codes 21025-21049, 21141-21147, 21150, 21151, 21193-21196, 21198, 21199, 21244-21255, 21440-21470, 70100, 70110, 70140, 70150, 70250, 70260 removed from covered table.
|
21070
|
Remove coronoid process
|
HCPCS
|
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered. CPT codes 64555-64595, 90875, 90876, 97012, 97110, 97112, 97530, 97799 added to non-covered. CPT codes 21025-21049, 21141-21147, 21150, 21151, 21193-21196, 21198, 21199, 21244-21255, 21440-21470, 70100, 70110, 70140, 70150, 70250, 70260 removed from covered table.
|
21049
|
PR EXC B9 TUM/CST MAXL XTR-ORAL OSTEOT&PRTL MAXLC
|
HCPCS
|
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered. CPT codes 64555-64595, 90875, 90876, 97012, 97110, 97112, 97530, 97799 added to non-covered. CPT codes 21025-21049, 21141-21147, 21150, 21151, 21193-21196, 21198, 21199, 21244-21255, 21440-21470, 70100, 70110, 70140, 70150, 70250, 70260 removed from covered table.
|
21196
|
Reconst lwr jaw w/fixation
|
HCPCS
|
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered. CPT codes 64555-64595, 90875, 90876, 97012, 97110, 97112, 97530, 97799 added to non-covered. CPT codes 21025-21049, 21141-21147, 21150, 21151, 21193-21196, 21198, 21199, 21244-21255, 21440-21470, 70100, 70110, 70140, 70150, 70250, 70260 removed from covered table.
|
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