Date Implemented |
Date Last Revised |
Revision Reason |
||
Rural Health Clinic |
12/27/02 |
11/16/07 |
Correction |
|
Category III CPT Codes |
09/29/07 |
04/03/08 |
Code Update |
|
Cardiac Rehabilitation |
09/30/06 |
03/11/08 |
Typo Correction |
|
Viscosupplementation Therapy (Hyaluronate) |
09/30/06 |
01/29/08 |
HCPCS Update |
|
Audiology |
09/30/06 |
04/03/08 |
Code Update |
|
Cardiac CT |
09/30/06 |
04/03/08 |
Code Update |
|
Virtual Colonoscopy |
09/30/06 |
10/30/07 |
Link Update |
|
Inpatient Rehabilitation |
08/01/07 |
04/23/08 |
Typographical Change |
|
(Retired 04/07/2006) Natrecor |
|
|
Retired |
|
Carboplatin |
09/30/05 |
06/21/07 |
Link Update |
|
[RETIRED 11/07/05] Dysphagia Services |
|
|
|
|
Percutaneous Vertebroplasty |
09/29/02 |
06/21/07 |
Link Update |
|
Kyphoplasty |
09/29/02 |
06/21/07 |
Link Update |
|
Infliximab |
09/29/02 |
06/21/07 |
Link Update |
|
Human Skin Equivalent |
09/29/02 |
04/03/08 |
Code Update |
|
Erythropoietin Analog |
09/29/02 |
04/03/08 |
Code Update |
|
Epoetin Alfa (Epogen, EPO, Erythropoietin) |
09/29/02 |
09/28/07 |
Code Update |
|
Removal of Benign Skin Lesions |
12/27/96 |
12/12/07 |
HCPCS Update |
|
Wireless Capsule Endoscopy |
09/29/02 |
10/30/07 |
Link Update |
|
Low Vision Rehabilitation |
09/29/04 |
12/12/07 |
Code Update |
|
Resynchronization Therapy for CHF |
09/29/04 |
06/25/07 |
Link Update |
|
Physical Medicine and Rehabilitation Modalities |
09/29/04 |
05/10/07 |
Revised Text |
|
Occupational Therapy |
09/30/05 |
10/30/07 |
Link Update |
|
Alefacept Therapy |
09/29/04 |
10/30/07 |
Link Update |
|
Oxaliplatin for Injection (Eloxitin) |
09/29/04 |
03/18/08 |
Link Update |
|
Troponin |
09/28/00 |
10/30/07 |
Link Update |
|
Transthoracic Echocardiography (TTE) |
08/04/05 |
05/14/08 |
Code Update |
|
Transrectal Echography for Prostatic Disease |
12/27/96 |
10/30/07 |
Link Update |
|
Syphilis Test |
10/16/97 |
10/30/07 |
Link Update |
|
Steroid Injections |
07/26/05 |
04/03/08 |
Code Update |
|
Potassium - Serum |
07/27/05 |
03/20/08 |
Code Update |
|
Hepatitis B |
07/22/95 |
03/20/08 |
Code Update |
|
Rheumatoid Factor Test |
10/16/97 |
10/30/07 |
Link Update |
|
Respiratory Therapy |
09/30/05 |
03/20/08 |
Code Update |
|
Pulmonary Rehabilitation |
06/01/02 |
01/09/07 |
Policy Number Update |
|
Removal Impacted Cerumen |
07/27/05 |
10/30/07 |
Link Update |
|
Pulmonary Perfusion Imaging |
08/06/05 |
09/27/07 |
Code Update |
|
Psychiatry and Psychology Services |
08/05/05 |
12/12/07 |
HCPCS Update |
|
Urinalysis |
05/15/98 |
03/20/08 |
Code Update |
|
HCG, Human Chorionic Gonadotropin Qualitative |
07/01/97 |
10/05/07 |
Link Update |
|
Prostatic Acid Phosphatase, PAP |
10/16/77 |
10/05/07 |
Link Update |
|
PRN Orders for Skilled Nursing Facilities |
04/01/98 |
10/05/07 |
Link Update |
|
Percutaneous Transluminal Angioplasy in Renal Dise |
12/27/96 |
05/24/07 |
Code Update |
|
Pelvic Echography for Prostate Follow-up |
08/04/05 |
10/05/07 |
Link Update |
|
Patient Education |
07/25/05 |
03/20/08 |
Code Update |
|
Partial Hospitalization |
07/26/05 |
11/29/07 |
Code Update |
|
Psychiatric Inpatient Hospitalization |
12/06/03 |
09/28/07 |
Code Update |
|
Psychiatric Services - Outpatient Hospital Based |
09/28/00 |
12/12/07 |
HCPCS Update |
|
Occult Blood - Feces |
10/16/97 |
12/12/07 |
HCPCS Update |
|
Wound Care |
12/06/03 |
11/16/07 |
HCPCS Update |
|
Noninvasive Vascular Studies |
12/27/96 |
03/20/08 |
Code Update |
|
Barium Swallow (Vedio/Cine) |
10/16/97 |
10/04/07 |
Code Update |
|
Bone Density Measurement |
01/01/98 |
03/07/08 |
Code Update |
|
Magnesium |
07/26/05 |
09/17/07 |
Code Update |
|
Lumbosacral Spine X-ray |
07/26/05 |
03/20/08 |
Code Update |
|
Dialysis Frequency |
09/30/03 |
04/03/08 |
CodeUpdate |
|
Renal and Iliac Angio and Aortography |
09/30/03 |
12/19/07 |
HCPCS Update |
|
ESWT for Musculoskeletal Problems |
09/30/03 |
10/05/07 |
Link Update |
|
Lumbar Spine MRI |
07/26/05 |
03/20/08 |
Code Update |
|
Adenosine (Adenocard) |
09/30/03 |
10/02/07 |
Link Update |
|
Neupogen and Neulasta |
09/30/03 |
05/23/08 |
Link Update |
|
Ferrlecit and Venofer |
09/30/03 |
10/02/07 |
Link Update |
|
Intensity Modulated Radiation Therapy (IMRT) |
09/30/03 |
03/18/08 |
Link Update |
|
Mohs Micrographic Surgery |
12/08/05 |
10/04/07 |
Code Update |
|
Botulinum Toxin Type A |
12/27/96 |
10/02/07 |
Code Additions |
|
Non-Covered Services |
09/30/03 |
11/29/07 |
HCPCS Update |
|
Blood Glucose Testing |
07/22/05 |
03/20/08 |
Code Update |
|
Off-Label Coverage of FDA Approved Drugs and Bio |
09/30/03 |
05/14/08 |
CodeUpdate |
|
(Retired 04/01/2006) Bariatric Surgery |
|
|
|
|
Blepharoplasty |
09/28/00 |
10/02/07 |
Link Update |
|
Bladder Tumor Antigen |
07/1997 |
10/02/07 |
Link Update |
|
Bacterial Culture |
10/19/97 |
09/17/07 |
Code Update |
|
Anesthesia for Transvenous Pacemaker Insertion |
07/26/05 |
10/02/07 |
Link Update |
|
Acute Care: Inpatient, Observation and Treatment |
06/01/02 |
12/12/07 |
HCPCS Update |
|
Leuprolide/Goserelin |
10/16/97 |
10/02/07 |
Link Update |
|
Laser Assisted Uvulopalatoplasty (LAUP) |
08/04/05 |
10/02/07 |
Link Update |
|
Ionized Calcium |
07/26/05 |
03/20/08 |
Code Update |
|
IVIG Intravenous Immunoglobin |
06/01/02 |
03/20/08 |
Code Update |
|
Interventional Cardiology |
12/27/96 |
10/02/07 |
Link Update |
|
Injection, Tendon Sheath, Ligament, Trigge |
08/04/05 |
10/02/07 |
Link Update |
|
Injectable Iron Preparation |
07/19/05 |
03/19/08 |
Link Update |
|
Indocyanine Green Angiography |
12/27/96 |
09/17/07 |
Link Update |
|
Impotency Treatment |
08/04/05 |
09/17/07 |
Link Update |
|
Ifosfamide (Ifex) |
07/26/05 |
03/19/08 |
Link Update |
|
Electrocardiographic Monitoring for 24 hours |
07/12/00 |
03/19/08 |
Link Update |
|
Ground Ambulance |
06/01/02 |
12/27/07 |
Policy Correction |
|
Flow Cytometry |
12/06/05 |
09/10/07 |
Code Update |
|
Electrophysiology Studies, EPS |
07/26/05 |
12/12/07 |
HCPCS Update |
|
Electrocardiogram |
04/01/98 |
03/19/08 |
Link Update |
|
Diagnostic Mammogram |
10/16/97 |
09/10/07 |
Link Update |
|
Colonoscopy |
12/27/96 |
09/10/07 |
Link Update |
|
Chest X-ray |
07/19/05 |
03/19/08 |
Link Update |
|
Cardiac Catheterization |
03/15/99 |
03/11/08 |
Narrative Change |
|
(Converted to LCD) Psychiatric Inpatient Hosp |
12/06/03 |
12/14/05 |
Converted to L13725 |
|
(Converted to LCD) Wound Care |
12/06/03 |
12/14/05 |
Converted to L13570 |
|
(Converted to LCD) Bariatric Surgery |
09/30/03 |
12/13/05 |
Converted to L13093 |
|
(Converted to LCD) Renal and Iliac Angio and |
09/30/03 |
12/13/05 |
Converted to L13295 |
|
(Converted to LCD) Dialysis Frequency |
09/30/03 |
12/13/05 |
Converted to L13302 |
|
(Converted to LCD) ESWT for Musculoskeletal Proble |
09/30/03 |
12/16/05 |
Converted to L13281 |
|
(Converted to LCD) Adenosine (Adenocard) |
09/30/03 |
12/16/05 |
Converted to L13243 |
|
(Converted to LCD) Neupogen and Neulasta |
09/30/03 |
12/13/05 |
Converted to L13239 |
|
(Converted to LCD) Ferrlecit and Venofer |
09/30/03 |
12/13/05 |
Converted to L13232 |
|
(Converted to LCD) Intensity Modulated Radiation |
09/30/03 |
11/01/05 |
Converted to L13228 |
|
(Converted to LCD) Mohs Micrographic Surgery |
09/30/03 |
12/08/05 |
Converted to L13225 |
|
(Converted to LCD) Off-Label Coverage of FDA Appr |
09/30/03 |
12/16/05 |
Converted to L13121 |
|
(Converted to LCD) Erythropoietin Analogs |
09/29/02 |
12/14/05 |
Converted to L1942 |
|
(Converted to LCD) Epoetin Alfa |
09/29/02 |
12/15/05 |
Converted to L1938 |
|
(Converted to LCD) Infliximab |
09/29/02 |
12/13/05 |
Converted to L1948 |
|
(Converted to LCD) Human Skin Equivalent |
09/29/02 |
12/16/05 |
Converted to L1944 |
|
(Converted to LCD) Kyphoplasty |
09/29/02 |
12/15/05 |
Converted to L1951 |
|
(Converted to LCD) Percutaneous Vertebroplasty |
09/29/02 |
12/13/05 |
Converted to L1959 |
|
(Converted to LCD) Wireless Capsule Endoscopy |
09/29/02 |
12/13/05 |
Converted to L1831 |
|
(Converted to LCD) Rural Health Clinic |
12/27/02 |
12/28/05 |
Converted to L4874 |
|
(Converted to LCD) Pulmonary Rehabilitation |
06/01/02 |
12/05/03 |
Converted to L1605 |
|
(Converted to LCD) Electrocardiographic Monitoring |
07/12/00 |
12/13/05 |
Converted to L1241 |
|
(Converted to LCD) Troponin |
09/28/00 |
12/13/05 |
Converted to L1686 |
|
[RETIRED 09/24/02] Self-administered Inj Drugs |
|
|
|
|
(Converted to LCD) Psychiatric Services-Outpatient |
09/28/00 |
12/15/05 |
Converted to L1372 |
|
(Converted to LCD) Blepharoplasty |
09/28/00 |
10/31/02 |
Converted to L1306 |
|
(Converted to LCD) HCG, Human Chorionic Gonado |
07/01/97 |
12/07/05 |
Converted to L1565 |
|
[RETIRED 01/13/03] CA19-9 Tumor Antigen |
|
|
|
|
[RETIRED 01/13/03] CA15-CA27.29 Tumor Antigen |
|
|
|
|
[RETIRED 01/13/03] CA125 Tumor Antigen |
|
|
|
|
[RETIRED 01/13/03] Alpha-fetoprotein Tumor Antigen |
|
|
|
|
(Converted to LCD) Bladder Tumor Antigen |
07/1997 |
12/07/05 |
Converted to L1303 |
|
[RETIRED 01/13/03] CEA Carcinoembryonic Antigen |
|
|
|
|
[RETIRED 01/13/03] Blood Count (CBC) |
|
|
|
|
[RETIRED 01/13/03 HIV] Testing (Diagnostic) |
|
|
|
|
[RETIRED 01/13/03] Lipid Profile |
|
|
|
|
(Converted to LCD) Cardiac Catheterization |
03/15/99 |
12/07/05 |
Converted to L1068 |
|
(Converted to LCD) Urinalysis |
05/15/98 |
12/07/05 |
Converted to L1567 |
|
(Retired 09/30/2005) Respiratory Therapy |
|
|
|
|
(Retired 12/31/2005) Speech Therapy |
05/15/98 |
02/17/05 |
Code Update |
|
[RETIRED 06/01/02] Observation Room Services |
|
|
|
|
(Converted to LCD) PRN Orders for Skilled Nursing |
04/01/98 |
12/07/05 |
|
|
(Converted to LCD) Electrocardiogram |
04/01/98 |
12/07/05 |
Converted to L1137 |
|
(Retired 12/31/2005) Physical Therapy |
01/01/98 |
01/31/05 |
Text Revision |
|
(Converted to LCD) Bone Density Measurement |
01/01/98 |
12/07/05 |
Converted to L1343 |
|
[RETIRED 01/13/03] Bacterial Culture, Urine |
|
|
|
|
[RETIRED] Sedimentation Rate, Erythrocyte |
|
|
|
|
(Converted to LCD) Rheumatoid Factor Test |
10/16/05 |
12/07/05 |
Converted to L1628 |
|
(Converted to LCD) Syphilis Test |
10/16/05 |
12/07/05 |
Converted to L1669 |
|
(Converted to LCD) Prostatic Acid Phosphatase, PAP |
10/16/97 |
12/07/05 |
Converted to L1428 |
|
(Converted to LCD) Bacterial Culture |
10/19/05 |
09/18/05 |
Converted to L1297 |
|
(Converted to LCD) Barium Swallow (Video/Cine) |
10/16/97 |
12/06/05 |
Converted to L1348 |
|
(Converted to LCD) Leuprolide/Goserelin |
10/16/97 |
12/06/05 |
Converted to L1266 |
|
(Converted to LCD) Occult Blood - Feces |
10/16/97 |
12/06/05 |
Converted to L1363 |
|
(Converted to LCD) Diagnostic Mammogram |
10/16/97 |
12/06/05 |
Converted to L1130 |
|
[RETIRED] Immunoassay for Tumor Antigen |
|
|
|
|
(Converted to LCD) Percutaneous Transluminal |
12/27/96 |
12/06/05 |
Converted to L1413 |
|
[RETIRED] Serum Cholesterol |
|
|
|
|
(Converted to LCD) Botulinum Toxin Type A |
12/27/96 |
12/06/05 |
Converted to L1321 |
|
(Converted to LCD) Interventional Cardiology |
12/27/96 |
12/06/05 |
Converted to L1249 |
|
(Converted to LCD) Colonoscopy |
12/27/96 |
12/06/05 |
Converted to L1116 |
|
(Converted to LCD) Indocyanine Green Angiography |
12/27/96 |
12/06/05 |
Converted to L1244 |
|
[RETIRED] CBC with Platelet Counts |
|
|
|
|
(Converted to LCD) Noninvasive Vascular Studies |
12/27/96 |
07/24/03 |
Converted to L1352 |
|
(Converted to LCD) Flow Cytometry |
12/27/96 |
12/06/05 |
Converted to L1140 |
|
(Converted to LCD) Psychiatry and Psychology Servi |
08/06/05 |
08/06/05 |
Converted to L1593 |
|
[RETIRED] Nerve Conduction/Latency Study: Motor |
|
|
|
|
(Converted to LCD) Pulmonary Perfusion Imaging |
08/06/05 |
08/06/05 |
Converted to L1594 |
|
(Converted to LCD) Pelvic Echography for Prostate |
08/04/05 |
08/04/05 |
Converted to L1412 |
|
(Converted to LCD) Transthoracic Echocardiography |
08/04/05 |
08/04/05 |
Converted to LCD |
|
(Converted to LCD) Injection, Tendon Sheath, Liga |
08/04/05 |
08/04/05 |
Converted to L1248 |
|
(Converted to LCD) Injectable Iron Preparation |
07/18/05 |
07/18/05 |
Converted to L1247 |
|
(Converted to LCD) Impotency Treatment |
08/04/05 |
08/04/05 |
Converted to L1243 |
|
(Converted to LCD) Laser Assisted Uvulopalatoplasy |
08/04/05 |
08/04/05 |
Converted to L1264 |
|
(Converted to LCD) Removal Impacted Cerumen |
07/27/05 |
07/27/05 |
Converted to L1597 |
|
(Converted to LCD) Potassium - Serum |
07/27/05 |
07/27/05 |
Converted to L1642 |
|
[RETIRED 01/13/03] Prothrombin Time |
|
|
|
|
(Converted to LCD) Steroid Injections |
7/26/05 |
7/26/05 |
Converted to L1664 |
|
(Converted to LCD) Anesthesia for Transvenous Pac |
07/26/05 |
07/26/05 |
Converted to L1290 |
|
(Converted to LCD) Lumbar Spine MRI |
07/26/05 |
07/26/05 |
Converted to L1326 |
|
(Converted to LCD) Lumbosacral Spine X-ray |
07/26/05 |
07/06/05 |
Converted to L1338 |
|
[RETIRED] Right Heart Catheterization |
|
|
|
|
(Converted to LCD) Electrophysiology Studies EPS |
07/26/05 |
07/26/05 |
Converted to L1139 |
|
[RETIRED] Low Osmolar Contrast Material |
|
|
|
|
[RETIRED] Additional Automated Hemogram Indices |
|
|
|
|
[RETIRED] CBC with Differential |
|
|
|
|
(Converted to LCD) Ionized Calcium |
07/26/05 |
07/26/05 |
Converted to L1257 |
|
[RETIRED 01/13/03] Glycated Protein |
|
|
|
|
(Converted to LCD) Ifosfamide (Ifex) |
07/26/05 |
07/26/05 |
Converted to L1242 |
|
[RETIRED 01/13/03] Iron Studies |
|
|
|
|
(Converted to LCD) Magnesium |
07/26/05 |
07/06/05 |
Converted to L1340 |
|
[RETIRED 01/13/03] Thyroid Panel |
|
|
|
|
(Converted to LCD) Partial Hospitalization |
07/26/05 |
07/06/05 |
Converted to L1379 |
|
[RETIRED 01/13/03] Digoxin |
|
|
|
|
(Converted to LCD) Patient Education |
07/25/05 |
07/25/05 |
Converted to L1406 |
|
(Converted to LCD) Blood Glucose Testing |
07/22/05 |
07/22/05 |
Converted to L1316 |
|
(Converted to LCD) Hepatitis B |