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Date Printed: August 18, 2017: 10:31 AM

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

09-A0000-00

Original Effective Date: 08/15/02

Revised: 08/15/17

Subject: Non-Covered Services

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

The codes listed below in the attached matrix identify services that are non-covered. These services may be non-covered because of one of the following:

NOTE: A service, procedure, device, or equipment that has been issued a CPT or HCPCS code, or is approved by the Food Drug and Administration (FDA) does not mean that the service procedure, device, or equipment is covered. Refer to subscriber’s/member’s contract benefits to determine if the service, procedure, device, or equipment in question is covered under the subscriber’s/member’s benefit plan. The services, procedures, devices, and equipment listed below are considered non-covered unless stated otherwise in the current member contract.

POSITION STATEMENT:

The codes listed in the matrix below are non-covered services and are not all inconclusive. Refer to the Medical Coverage Guidelines index for coverage for other service(s), procedure(s), device(s), and/or equipment that is not listed in the matrix below.

NOTE: For Medicare Advantage products, see the Program Exceptions section of this guideline.

CODE

DESCRIPTOR

COVERAGE

01990

Physiological support for harvesting of organ(s) from brain-dead patient

Refer to Member Contract

83037

Hemoglobin; glycosylated (A1C) by device cleared by FDA for home use

Test is normally performed in the office or the lab, not in the home

88000

Necropsy (autopsy), gross examination only; without CNS

Refer to Member Contract

88005

Necropsy (autopsy), gross examination only; with brain

Refer to Member Contract

88007

Necropsy (autopsy), gross examination only; with brain and spinal cord

Refer to Member Contract

88012

Necropsy (autopsy), gross examination only; infant with brain

Refer to Member Contract

88014

Necropsy (autopsy), gross examination only; stillborn or newborn with brain

Refer to Member Contract

88016

Necropsy (autopsy), gross examination only; macerated stillborn

Refer to Member Contract

88020

Necropsy (autopsy), gross and microscopic; without CNS

Refer to Member Contract

88025

Necropsy (autopsy), gross and microscopic; with brain

Refer to Member Contract

88027

Necropsy (autopsy), gross and microscopic; with brain and spinal cord

Refer to Member Contract

88028

Necropsy (autopsy), gross and microscopic; infant with brain

Refer to Member Contract

88029

Necropsy (autopsy), gross and microscopic; stillborn or newborn with brain

Refer to Member Contract

88036

Necropsy (autopsy), limited, gross AND/OR microscopic; regional

Refer to Member Contract

88037

Necropsy (autopsy), limited, gross AND/OR microscopic; single organ

Refer to Member Contract

88040

Necropsy (autopsy), forensic examination

Refer to Member Contract

88045

Necropsy (autopsy), forensic examination coroner’s call

Refer to Member Contract

88099

Unlisted necropsy (autopsy) procedure

Refer to Member Contract

90587

Dengue vaccine, quadrivalent, live, 3 dose schedule, for subcutaneous

FDA approval pending

90750

Zoster (shingles) vaccine (HZV), recombinant, sub-unit, adjuvanted, for intramuscular injection

FDA approval pending

92015

Determination of refractive state

Refer to Member Contract

92065

Orthoptic AND/OR pleoptic training, with continuing medical direction and evaluation (vision therapy)

Refer to Member Contract

93668

Peripheral arterial disease (PAD) rehabilitation, per session

Refer to Member Contract

96902

Microscopic examination of hairs plucked or clipped by the examiner (excluding hair collected by the patient) to determine telogen and anagen counts, or structural hair shaft abnormality

Refer to Member Contract

97169

Athletic training evaluation, low complexity, requiring these components: A history and physical activity profile with no comorbidities that affect physical activity; An examination of affected body area and other symptomatic or related systems addressing 1-2 elements from any of the following: body structures, physical activity, and/or participation deficiencies; and Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 15 minutes are spent face-to-face with the patient and/or family.

Refer to Member Contract

97170

Athletic training evaluation, moderate complexity, requiring these components: A medical history and physical activity profile with 1-2 comorbidities that affect physical activity; An examination of affected body area and other symptomatic or related systems addressing a total of 3 or more elements from any of the following: body structures, physical activity, and/or participation deficiencies; and Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 30 minutes are spent face-to-face with the patient and/or family.

Refer to Member Contract

97171

Athletic training evaluation, high complexity, requiring these components: A medical history and physical activity profile, with 3 or more comorbidities that affect physical activity; A comprehensive examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures, physical activity, and/or participation deficiencies; Clinical presentation with unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient and/or family.

Refer to Member Contract

97172

Re-evaluation of athletic training established plan of care requiring these components: An assessment of patients current functional status when there is a documented change; and A revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome with an update in management options, goals, and interventions. Typically, 20 minutes are spent face-to-face with the patient and/or family.

Refer to Member Contract

97545

Work hardening/conditioning; initial 2 hours

Refer to Member Contract

97546

Work hardening/conditioning; each additional hour (List separately in addition to code for primary procedure)

Refer to Member Contract

99026

Hospital mandated on call service; in-hospital, each hour

Refer to Member Contract

99027

Hospital mandated on call service; out-of-hospital, each hour

Refer to Member Contract

99056

Service(s) typically provided in the office, provided out of the office at request of patient, in addition to basic service

Refer to Member Contract

99060

Service(s) provided on an emergency basis, out of the office, which disrupts other scheduled office services, in addition to basic service

Refer to Member contract

99075

Medical testimony

Refer to Member Contract

99080

Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form

Refer to Member Contract

99082

Unusual travel (e.g., transportation and escort of patient)

Refer to Member Contract

99090

Analysis of clinical data stored in computers (e.g., ECGs, blood pressures, hematologic data)

Refer to Member Contract

99339

Individual physician supervision of a patient (patient not present) in home, domiciliary or rest home (e.g., assisted living facility) requiring complex and multidisciplinary care modalities involving regular physician development AND/OR revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (e.g., legal guardian) and/or key caregiver(s) involved in patient’s care, integration of new information into the medical treatment plan AND/OR adjustment of medical therapy, within a calendar month; 15-29 minutes

Refer to Member Contract

99340

Individual physician supervision of a patient (patient not present) in home, domiciliary or rest home (e.g., assisted living facility) requiring complex and multidisciplinary care modalities involving regular physician development AND/OR revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (e.g., legal guardian) AND/OR key caregiver(s) involved in patient’s care, integration of new information into the medical treatment plan AND/OR adjustment of medical therapy, within a calendar month; 30 minutes or more

Refer to Member Contract

99366

Medical team conference with interdisciplinary team of health care professionals, face-to-face with patient and/or family, 30 minutes or more, participation by nonphysician qualified health care professional

Refer to Member Contract

99367

Medical team conference with interdisciplinary team of health care professionals, patient, and/or family not present, 30 minutes or more; participation by physician

Refer to Member Contract

99368

Medical team conference with interdisciplinary team of health care professionals, patient, and/or family not present, 30 minutes or more; participation by nonphysician qualified health care professional

Refer to Member Contract

99375

Supervision of a patient under care of home health agency (patient not present) in home, domiciliary or equivalent environment (e.g., Alzheimer’s facility) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment of care decisions with health care professionals(s), family member(s), surrogate decision maker(s) (e.g., legal guardian) and/or key caregiver(s) involved in patient’s care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 30 minutes or more

Refer to Member Contract

99378

Supervision of a hospice patient (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment of care decisions with health care professionals(s), family member(s), surrogate decision maker(s) (e.g., legal guardian) and/or key caregiver(s) involved in patient’s care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 30 minutes or more

Refer to Member Contract

99380

Supervision of a nursing facility patient (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of a care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment of care decisions with health care professional(s), family members(s), surrogate decision maker(s) (e.g., legal guardian) and/or key caregiver(s) involved in patient’s care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 30 minutes or more

Refer to Member Contract

99446

Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 5-10 minutes of medical consultative discussion and review

Refer to Member Contract

99447

Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 11-20 minutes of medical consultative discussion and review

Refer to Member Contract

99448

Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 21-30 minutes of medical consultative discussion and review

Refer to Member Contract

99449

Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 31 minutes or more of medical consultative discussion and review

Refer to Member Contract

99450

Basic life AND/OR disability examination that includes:·measurement of height, weight and blood pressure;·completion of a medical history following a life insurance pro forma;·collection of blood sample AND/OR urinalysis complying with “chain of custody” protocols; completion of necessary documentation/certificates.

Refer to Member Contract

99455

Work related OR medical disability examination by the treating physician that includes: completion of a medical history commensurate with the patient’s condition;·performance of an examination commensurate with the patient’s condition;·formulation of a diagnosis, assessment of capabilities and stability, and calculation of impairment;· development of future medical treatment plan; and completion of necessary documentation/certificates and report.

Refer to Member Contract

99456

Work related OR medical disability examination by the other than the treating physician that includes:· completion of a medical history commensurate with the patient’s condition;·performance of an examination commensurate with the patient’s condition;·formulation of a diagnosis, assessment of capabilities and stability, and calculation of impairment; development of future medical treatment plan; and completion of necessary documentation/certificates and report.

Refer to Member Contract

99510

Home visit for individual, family, or marriage counseling

Refer to Member Contract

99605

Medication therapy management service(s) provided by a pharmacist, individual, face-to-face, with patient, with assessment and intervention if provided; initial 15 minutes, new patient

Pharmacists are only allowed to dispense.

99606

Medication therapy management service(s) provided by a pharmacist, individual, face-to-face, with patient, with assessment and intervention if provided; initial 15 minutes, established patient

Pharmacists are only allowed to dispense.

99607

Medication therapy management service(s) provided by a pharmacist, individual, face-to-face, with patient, with assessment and intervention if provided; each additional 15 minutes (List separately in addition to code for primary service)

Pharmacists are only allowed to dispense.

A4218

Sterile saline or water, metered dose dispenser, 10 ml

Refer to Member Contract

A4244

Alcohol OR peroxide, per pint

Refer to Member Contract

A4245

Alcohol wipes, per box

Refer to Member Contract

A4246

Betadine OR pHisoHex solution, per pint

Refer to Member Contract

A4247

Betadine OR iodine swabs/wipes, per box

Refer to Member Contract

A4248

Chlorhexidine containing antiseptic, 1 ml

Refer to Member Contract

A4281

Tubing for breast pump, replacement

Refer to 09-E0000-01 Durable Medical Equipment (DME); Attached Table

A4282

Adapter for breast pump, replacement

Refer to 09-E0000-01 Durable Medical Equipment (DME); Attached Table

A4283

Cap for breast pump bottle, replacement

Refer to 09-E0000-01 Durable Medical Equipment (DME); Attached Table

A4284

Breast shield and splash protector for use with breast pump, replacement

Refer to 09-E0000-01 Durable Medical Equipment (DME); Attached Table

A4285

Polycarbonate bottle for use with breast pump, replacement

Refer to 09-E0000-01 Durable Medical Equipment (DME); Attached Table

A4286

Locking ring for breast pump, replacement

Refer to 09-E0000-01 Durable Medical Equipment (DME); Attached Table

A4456

Adhesive remover, wipes, any type, each

Refer to Member Contract

A4458

Enema bag with tubing, reusable

Refer to Member Contract

A4467

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

Refer to Member Contract

A4520

Incontinence garment, any type, (e.g., brief, diaper), each

Refer to Member Contract Incontinence garments are excluded by most contracts.

A4553

Non-disposable underpads, all sizes

Refer to Member Contract

A4554

Disposable underpads, all sizes (e.g., Chuxs)

Refer to Member Contract

A4601

Lithium ion battery, rechargeable, for non-prosthetic use, replacement

Contract exclusion (over-the-counter item)

A4633

Replacement bulb/lamp for ultraviolet light therapy system, each

Refer to 09-E0000-01 Durable Medical Equipment (DME); Attached Table

A4634

Replacement bulb for therapeutic light box, tabletop model

Refer to 09-E0000-01 Durable Medical Equipment (DME); Attached Table

A4660

Sphygmomanometer/blood pressure apparatus with cuff and stethoscope

Refer to Member Contract

A4663

Blood pressure cuff only

Refer to Member Contract

A4927

Gloves, non-sterile, for dialysis, per 100

Refer to Member Contract

A4931

Oral thermometer, reusable; any type, each

Refer to Member Contract

A4932

Rectal thermometer, reusable, any type, each

Refer to Member Contract

A6402

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

Refer to Member Contract

A6403

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

Refer to Member Contract

A6404

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

Refer to Member Contract

A8000

Helmet, protective soft, prefabricated, includes all components and accessories

Refer to Member Contract

A8001

Helmet, protective, hard, prefabricated, includes all components and accessories

Refer to Member Contract

A8002

Helmet, protective, soft, custom fabricated, includes all components and accessories

Refer to Member Contract

A8003

Helmet, protective, hard, custom fabricated, includes all components, and accessories

Refer to Member Contract

A8004

Soft interface for helmet, replacement only

Refer to Member Contract

A9150

Non-prescription drug

Refer to Member Contract

A9270

Non-covered item or service

Refer to Member Contract

A9273

Hot water bottle, ice cap or collar, heat and/or cold wrap, any type

Refer to Member Contract

A9275

Home glucose disposable monitor, includes test strips

Refer to Member Contract

A9281

Reaching/grabbing device, any type, any length each

Refer to Member Contract

A9283

Foot pressure off loading/supportive device, any type, each

Refer to Member Contract

A9285

Inversion/eversion correction device

Refer to Member Contract

A9286

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

Refer to Member Contract

A9300

Exercise equipment

Refer to Member Contract

D0480

Processing and interpretation of cytologic smears, including the preparation and transmission of written report

Refer to Member Contract

D1330

Oral hygiene instructions

Refer to Member Contract

D9310

Consultation (diagnostic service provided by dentist or physician other than practitioner providing treatment)

BCBSF uses another code for reporting of, and consideration of payment for, these services

E0170

Commode chair with integrated seat lift mechanism, electric, any type

Refer to 09-E0000-01 Durable Medical Equipment (DME); Attached Table

E0171

Commode chair with integrated seat lift mechanism, non-electric, any type

Refer to 09-E0000-01 Durable Medical Equipment (DME); Attached Table

E0172

Seat lift mechanism placed over or on top of toilet, any type

Refer to Member Contract

E0175

Foot rest, for use with commode chair, each

Refer to Member Contract

E0189

Lambswool sheepskin pad, any size

Refer to 09-E0000-01 Durable Medical Equipment (DME); Attached Table

E0200

Heat lamp, without stand (table model), includes bulb, or infrared element

Refer to 09-E0000-01 Durable Medical Equipment (DME); Attached Table

E0203

Therapeutic light box, minimum 10,000 lux, table top model

Refer to 09-E0000-01 Durable Medical Equipment (DME); Attached Table

E0205

Heat lamp, with stand, includes bulb, or infrared element

Refer to 09-E0000-01 Durable Medical Equipment (DME); Attached Table

E0210

Heating pad, standard

Refer to Member Contract

E0215

Electric heat pad, moist

Refer to 09-E0000-01 Durable Medical Equipment (DME); Attached Table

E0225

Hydrocollator unit, includes pads

Refer to 09-E0000-01 Durable Medical Equipment (DME); Attached Table

E0239

Hydrocollator unit, portable

Refer to 09-E0000-01 Durable Medical Equipment (DME); Attached Table

E0241

Bathtub wall rail, each

Refer to 09-E0000-01 Durable Medical Equipment (DME); Attached Table

E0242

Bathtub rail, floor base

Refer to 09-E0000-01 Durable Medical Equipment (DME); Attached Table

E0243

Toilet rail, each

Refer to Member Contract

E0244

Raised toilet seat

Refer to Member Contract

E0245

Tub stool or bench

Refer to Member Contract

E0246

Transfer tub rail attachment

Refer to 09-E0000-01 Durable Medical Equipment (DME); Attached Table

E0249

Pad for water circulating heat unit, for replacement only

Refer to 09-E0000-01 Durable Medical Equipment (DME); Attached Table

E0370

Air pressure elevator for heel

Refer to Member Contract

E0604

Breast pump, heavy duty, hospital grade, piston operated, pulsatile vacuum suction/release cycles, vacuum regulator, supplies, transformer, electric (AC and/or DC)

Refer to 09-E0000-01 Durable Medical Equipment (DME); Attached Table

E0636

Multi-positional patient support system, with integrated lift, patient accessible controls

Refer to 09-E0000-01 Durable Medical Equipment (DME); Attached Table

E0639

Patient lift, movable from room to room with disassembly and reassembly, includes all components /accessories

Refer to 09-E0000-01 Durable Medical Equipment (DME); Attached Table

E0640

Patient lift, fixed system, includes all components / accessories

Refer to 09-E0000-01 Durable Medical Equipment (DME); Attached Table

E0641

Standing frame/table system, multi-position (e.g., three-way stander), any size including pediatric, with or without wheels

Refer to 09-E0000-01 Durable Medical Equipment (DME); Attached Table

E0642

Standing frame/table system, mobile (dynamic stander), any size including pediatric

Refer to 09-E0000-01 Durable Medical Equipment (DME); Attached Table

E0705

Transfer device, any type, each

Refer to 09-E0000-01 Durable Medical Equipment (DME); Attached Table

E1031

Roll-about chair, any and all types with casters five inches or greater

Refer to Member Contract

E1035

Multi-positional patient transfer system, with integrated seat, operated by care giver, patient weight up to and including 300 lbs.

Refer to 09-E0000-01 Durable Medical Equipment (DME); Attached Table

E1036

Multi-positional patient transfer system, extra-wide, with integrated seat, operated by care giver, patient weight capacity greater than and including 300 lbs.

Refer to 09-E0000-01 Durable Medical Equipment (DME); Attached Table

E1310

Whirlpool, non-portable (built-in type)

Refer to 09-E0000-01 Durable Medical Equipment (DME); Attached Table

E1372

Immersion external heater for nebulizer

Refer to Member Contract

E1639

Scale, each

Refer to Member Contract

E1902

Communication board, non-electronic augmentative or alternative communication device

Refer to Member Contract

G0182

Physician supervision of a patient under a Medicare-approved hospice (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, preview of subsequent reports of patient status, review, review of laboratory and other studies, communication (including telephone calls) patient’s care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month, 30 minutes or more

Refer to Member Contract

G0293

Non-covered surgical procedure(s) using conscious sedation, regional, general or spinal anesthesia in a Medicare qualifying clinical trial, per day

Refer to Member Contract

G0294

Non-covered surgical procedure(s) using anesthesia or local anesthesia only in a Medicare qualifying clinical trial, per day

Refer to Member Contract

G0406

Follow-up inpatient consultation, limited, physicians typically spend 15 minutes communicating with the patient via telehealth

Refer to Member Contract

G0407

Follow-up inpatient consultation, intermediate, physicians typically spend 25 minutes communicating with the patient via telehealth

Refer to Member Contract

G0408

Follow-up inpatient consultation, complex physicians typically spend 35 minutes communicating with the patient via telehealth

Refer to Member Contract

G0428

Meniscus implant procedure for filling meniscal defects (e.g., CMI, collagen scaffold, Menaflex)

Refer to Member Contract

G0429

Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (e.g., as a result of highly active antiretroviral therapy)

Refer to Member Contract

G0508

Telehealth consultation, critical care, initial , physicians typically spend 60 minutes communicating with the patient and providers via telehealth

Refer to Member Contract

G0509

Telehealth consultation, critical care, subsequent, physicians typically spend 50 minutes communicating with the patient and providers via telehealth

Refer to Member Contract

G9016

Smoking cessation counseling, individual, in the absence of OR in addition to any other evaluation and management service, per session (6-10 minutes) [demo project only]

Refer to Member Contract

J3530

Nasal vaccine inhalation

Refer to Member Contract

J3570

Laetrile (AKA, Amygdalin, Vitamin B-17, Kemdalin)

Refer to Member Contract

L3030

Foot insert, removable, formed to patient foot, each

Refer to Member Contract

L6621

Upper extremity prosthesis addition, flexion/extension wrist with or without friction, for use with external powered terminal device

Refer to Member Contract

L7600

Prosthetic donning sleeve, any material, each

Refer to Member Contract

M0075

Cellular therapy

Refer to Member Contract

M0100

Intragastric hypothermia using gastric freezing (MNP)

Refer to Member Contract

M0301

Fabric wrapping for abdominal aneurysm (MNP)

Refer to Member Contract

P2029

Congo red, blood

Refer to Member Contract

P2031

Hair analysis (excluding arsenic)

Refer to Member Contract

P2038

Mucoprotein, blood (seromucoid) (medical necessity procedure)

Refer to Member Contract

Q3014

Telehealth originating site facility fee

Refer to Member Contract

S0012

Butorphanol tartrate, nasal spray, 25 mg

Refer to Member Contract

S0014

Tacrine hydrochloride, 10 mg

Refer to Member Contract

S0088

Imatinib, 100 mg

Refer to Member Contract

S0090

Sildenafil citrate, 25 mg

Refer to Member Contract

S0104

Zidovudine, oral 100mg

Refer to Member Contract

S0106

Bupropion HCL sustained release tablets, 150 mg. Per bottle of 60 tablets

Refer to Member Contract

S0108

Mercaptopurine, oral, 50 mg

Refer to Member Contract

S0156

Exemestane, 25 mg

Refer to Member Contract

S0170

Anastrozole, oral, 1mg

Refer to Member Contract

S0172

Chlorambucil, oral, 2mg

Refer to Member Contract

S0175

Flutamide, oral, 125 mg

Refer to Member Contract

S0176

Hydroxyurea, oral, 500 mg

Refer to Member Contract

S0177

Levamisole HCL, oral, 50mg

Refer to Member Contract

S0178

Lomustine, oral, 10mg

Refer to Member Contract

S0179

Megestrol acetate, oral, 20 mg

Refer to Member Contract

S0182

Procarbazine hydrochloride, oral, 50 mg

Refer to Member Contract

S0187

Tamoxifen citrate, oral, 10 mg

Refer to Member Contract

S0201

Partial hospitalization services, less than 24 hours, per diem

Refer to Member Contract

S0250

Comprehensive geriatric assessment and treatment planning performed by assessment team

Refer to Member Contract

S0340

Lifestyle modification program for management of coronary artery disease, including all supportive services; first quarter/stage

Refer to Member Contract

S0341

Lifestyle modification program for management of coronary artery disease, including all supportive services; second or third quarter/stage

Refer to Member Contract

S0342

Lifestyle modification program for management of coronary artery disease, including all supportive services; fourth quarter/stage

Refer to Member Contract

S0354

Cancer treatment plan, change

Refer to Member Contract

S0400

Global fee for extracorporeal shock wave lithotripsy treatment of kidney stone(s)

BCBSF uses another code for reporting of, and consideration of payment for these services; lithotripsy, extracorporeal shock wave

S0618

Audiometry for hearing aid evaluation to determine the level and degree of hearing loss

Refer to Member Contract

S0620

Routine ophthalmological examination including refraction; new patient

Refer to Member Contract

S0621

Routine ophthalmological examination including refraction; established patient

Refer to Member Contract

S1001

Deluxe item, patient aware (List in addition to the code for the basic item)

Refer to Member Contract

S1002

Customized item (List in addition to code for the basic item)

Refer to Member Contract

S2152

S2152 Solid organ(s), complete OR segmental, single organ OR combination of organs; deceased OR living donor(s), procurement, transplantation, and related complications; including: drugs; supplies; hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services, and the number of days of pre- and post- transplant care in the global definition

Refer to Member Contract

S2342

Nasal endoscopy for post-operative debridement following functional endoscopic sinus surgery, nasal AND/OR sinus cavity(s), unilateral or bilateral

BCBSF uses another code for reporting of, and consideration of payment for, these services (Refer to 31237)

S3600

Stat laboratory request (use for situations other than S3601)

Refer to Member Contract

S3601

Emergency stat laboratory charge for patient who is homebound or residing in a nursing facility

Refer to Member Contract

S4990

Nicotine patches, legend

Refer to Member Contract

S4991

Nicotine patches, non-legend

Refer to Member Contract

S4995

Smoking cessation gum

Refer to Member Contract

S5100

Day care services, adult; per 15 minutes

Refer to Member Contract

S5101

Day care services, adult; per half day

Refer to Member Contract

S5102

Day care services, adult; per diem

Refer to Member Contract

S5105

Day care services, center based; services not included in program fee, per diem

Refer to Member Contract

S5110

Home care training, family; per 15 minutes

Refer to Member Contract

S5111

Home care training, family; per session

Refer to Member Contract

S5115

Home care training, non-family; per 15 minutes

Refer to Member Contract

S5116

Home care training, family; per 15 minutes

Refer to Member Contract

S5120

Chore services; per 15 minutes

Refer to Member Contract

S5121

Chore services; per diem

Refer to Member Contract

S5125

Attendant care services; per 15 minutes

Refer to Member Contract

S5126

Attendant care services; per diem

Refer to Member Contract

S5130

Homemaker services, NOS; per 15 minutes

Refer to Member Contract

S5131

Homemaker services, NOS; per diem

Refer to Member Contract

S5135

Companion care, adult (e.g., IADL/ADL); per 15 minutes

Refer to Member Contract

S5136

Companion care, adult (e.g., IADL/ADL); per diem

Refer to Member Contract

S5140

Foster care, adult; per diem

Refer to Member Contract

S5141

Foster care, adult; per month

Refer to Member Contract

S5145

Foster care, therapeutic, child; per diem

Refer to Member Contract

S5146

Foster care, therapeutic, child; per month

Refer to Member Contract

S5150

Unskilled respite care, not Hospice; per 15 minutes

Refer to Member Contract

S5151

Unskilled respite care, not Hospice; per diem

Refer to Member Contract

S5160

Emergency response system; installation and testing

Refer to Member Contract

S5161

Emergency response system; service fee, per month (excludes installation and testing)

Refer to Member Contract

S5162

Emergency response system; purchase only

Refer to Member Contract

S5165

Home modifications; per service

Refer to Member Contract

S5170

Home delivered meals, including preparation; per meal

Refer to Member Contract

S5175

Laundry service, external, professional; per order

Refer to Member Contract

S8270

Enuresis alarm, using auditory buzzer and/or vibration device

Refer to 09-E0000-01 Durable Medical Equipment (DME); Attached Table

S8415

Supplies for home delivery of infant

Refer to Member Contract

S8460

Camisole, post-mastectomy

Refer to Member Contract

S8990

Physical or manipulative therapy performed for maintenance rather than restoration

Refer to Member Contract

S9110

Tele-monitoring of patient in their home, including all necessary equipment; computer system, connections, and software; maintenance; patient education and support; per month

Refer to Member Contract

S9117

Back school, per visit

Refer to Member Contract

S9145

Insulin pump initiation, instruction in initial use of pump

BCBSF uses another code for reporting of, and consideration of payment for, these services. (Refer to E0784)

S9381

Delivery OR service to high risk areas requiring escort or extra protection, per visit

Refer to Member Contract

S9401

Anticoagulation clinic, inclusive of all services except laboratory tests, per session

Refer to Member Contract

S9430

Pharmacy compounding and dispensing services

Not covered under a medical benefit

S9436

Childbirth preparation/Lamaze classes, non-physician provider, per session

Refer to Member Contract

S9437

Childbirth refresher classes, non-physician provider, per session

Refer to Member Contract

S9438

Cesarean birth classes, non-physician provider, per session

Refer to Member Contract

S9439

VBAC (vaginal birth after cesarean) classes, non-physician provider, per session

Refer to Member Contract

S9441

Asthma education, non-physician provider, per session

Refer to Member Contract

S9442

Birthing classes, non-physician provider, per session

Refer to Member Contract

S9444

Parenting classes, non-physician provider, per session

Refer to Member Contract

S9445

Patient education, not otherwise classified, non-physician provider, individual, per session

Refer to Member Contract

S9446

Patient education, not otherwise classified, non-physician provider, group, per session

Refer to Member Contract

S9447

Infant safety (including CPR) classes, non-physician provider, per session

Refer to Member Contract

S9449

Weight management classes, non-physician provider, per session

Refer to Member Contract

S9451

Exercise classes, non-physician provider, per session

Refer to Member Contract

S9452

Nutrition classes, non-physician provider, per session

Refer to Member Contract

S9453

Smoking cessation classes, non-physician provider, per session

Refer to Member Contract

S9454

Stress management classes, non-physician provider, per session

Refer to Member Contract

S9472

Cardiac rehabilitation program, non-physician provider, per diem

Refer to Member Contract

S9484

Crisis intervention mental health services, per hour

Refer to Member Contract

S9529

Routine venipuncture for collection of specimen(s), single home bound, nursing home, or skilled nursing facility patient

BCBSF uses another code for reporting of, and consideration of payment for, these services. (Refer to 36415)

S9900

Services by a journal-listed Christian Science Practitioner for the purpose of healing, per diem.

Refer to Member Contract

S9901

Services by a journal-listed christian science nurse, per hour

Refer to Member Contract

S9970

Health club membership, annual

Refer to Member Contract

S9981

Medical Records copying fee, administrative

Refer to Member Contract

S9982

Medical records copying, per page

Refer to Member Contract

S9986

Not medically necessary service (patient is aware that service is not medically necessary)

Refer to Member Contract

S9990

Services provided as part of a phase II clinical trial

Refer to Member Contract

S9991

Services provided as part of a phase III clinical trial

Refer to Member Contract

S9992

Transportation costs to and from trial location and local transportation costs (e.g., fares for taxicab or bus) for clinical trial participant and one caregiver/companion

Refer to Member Contract

S9994

Lodging costs (e.g., hotel charges) for clinical trial participant and one caregiver/companion

Refer to Member Contract

S9996

Meals for clinical trial participant and one companion/companion

Refer to Member Contract

S9999

Sales tax

Refer to Member Contract

T4543

Adult sized disposable incontinence product, protective brief/diaper, above extra large, each

Refer to Member Contract

V2600

Hand held low vision aids and other non-spectacle mounted aids

Refer to Member Contract

V2610

Single lens spectacle mounted low vision aids

Refer to Member Contract

V2615

Telescopic and other compound lens system, including distance vision telescopic, near vision telescopes and compound microscopic lens system

Refer to Member Contract

V2744

Tint, photo-chromatic, per lens

Refer to Member Contract

V2750

Antireflective coating, per lens

Refer to Member Contract

V2760

Scratch resistant coating, per lens

Refer to Member Contract

V5268

Assistive listening device, telephone amplifier, any type

Refer to Member Contract

V5269

Assistive listening device, alertive, any type

Refer to Member Contract

V5270

Assistive listening device, television amplifier, any type

Refer to Member Contract

V5271

Assistive listening device, television caption decoder

Refer to Member Contract

V5272

Assistive listening device, TDD

Refer to Member Contract

V5274

Assistive learning device, not otherwise specified

Refer to Member Contract

V5281

Assistive listening device, personal FM/DM system, monaural, (1 receiver, transmitter, microphone), any type

Refer to Member Contract

V5282

Assistive listening device, personal FM/DM system, binaural, (2 receivers, transmitter, microphone), any type

Refer to Member Contract

V5283

Assistive listening device, personal FM/DM neck, loop induction receiver

Refer to Member Contract

V5284

Assistive listening device, personal FM/DM, ear level receiver

Refer to Member Contract

V5285

Assistive listening device, personal FM/DM, direct audio input receiver

Refer to Member Contract

V5286

Assistive listening device, personal blue tooth FM/DM receiver

Refer to Member Contract

V5287

Assistive listening device, personal FM/DM receiver, not otherwise specified

Refer to Member Contract

V5288

Assistive listening device, personal FM/DM transmitter assistive listening device

Refer to Member Contract

V5289

Assistive listening device, personal FM/DM adapter/boot coupling device for receiver, any type

Refer to Member Contract

V5290

Assistive listening device, transmitter microphone, any type

Refer to Member Contract

Unlisted
Code

Transillumination light scanning (diaphanography)

Refer to Member Contract

BILLING/CODING INFORMATION:

“S” codes are developed by Blue Cross and Blue Shield and other commercial payers to report drugs, services, and supplies. The “S” codes are not to be used to bill services paid under any Medicare payment program. “S” codes are not payable by Medicare.

REIMBURSEMENT INFORMATION:

None applicable.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage Products:

National Coverage Determinations (NCDs) can be found at cms.gov.

Local Coverage Determinations (LCDs) can be found at fcso.com.

Durable Medical Equipment Regional Carrier (DMERC) Local Coverage Determinations (LCDs) can be found at cgsmedicare.com.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

Durable Medical Equipment Attached Table

OTHER:

None applicable.

REFERENCES:

  1. American Medical Association (AMA) CPT® Category I Vaccine Codes, 06/30/08.
  2. American Medical Association Current Procedural Terminology (CPT), 2008.
  3. Blue Cross Blue Shield Association Corneal Topography/Computer-Assisted Photokeratoscopy Medical Policy 9.03.05, 06/14/07.
  4. Centers for Medicare and Medicare Services (CMS) National Coverage Determination for Durable Medical Equipment Reference List, Publication 100-3, Section 280.1. Last updated 05/05/05.
  5. First Coast Service Options, Inc. – The List of Medicare Noncovered Services, 07/01/07.
  6. Florida Medicare Part B Local Coverage Determination. LCD for Patient Lifts (L11562). Last updated 01/01/09.
  7. Florida Medicare Part B Local Coverage Determination. LCD for Refractive Lenses (L11522). Last updated 01/01/09.
  8. Food and Drug Administration (FDA) Product Approval Information – KINRIX™ (Diphtheria and Tetanus Toxoids and Acellular Pertussis Adsorbed and Inactivated Poliovirus Vaccine), 06/08.
  9. HCPCS Level II Ingenix, current edition.
  10. Medicare Claims Processing Manual Chapter 20-Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), 11/22/06.
  11. Medicare National Coverage Determinations Manual Chapter 1, Part 1-Fabric Wrapping of Abdominal Aneurysms 20.23 and Cellular Therapy 30.8, 06/29/07.
  12. Medicare National Coverage Determinations Manual Chapter 1, Part 2-Gastric Freezing 100.6 and Transsexual Surgery 140.3, 06/22/07.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 08/23/07.

GUIDELINE UPDATE INFORMATION:

08/15/02

New Medical Coverage Guideline documenting existing BCBSF non-covered services.

01/01/03

HCPCS code additions, revisions, and deletions. Non-coverage status reversed for CPT codes 99050, 99052, and 99054.

02/15/03

CPT and HCPCS Codes 75556, 76400, 99378, A4458, E0273, E0575, E0744, S0104, S0201, S0207, S0620, S0621, S9470, and S9484, added for consistency with existing coverage. CPT Codes 96000, 96001, 96002, 96003, and 96004. Coverage changed from non-covered to investigational. CPT Code E0274 corrected to read E0315, Non-coverage status reversed for S0157 and S8185. HCPCS code deletions: S8400, S8402, S9216, and S0217.

03/15/03

Added CPT codes 97802, 97803, 97804, G0270 and G0271 for Medicare & More.

04/01/03

HCPCS code additions for 04/01/03. Added S8460, S8990 and S9434.

07/15/03

Added CPT code 90660.

08/15/03

Deleted code A4639.

08/29/03

Deleted CPT code 90660.

10/02/03

Deleted code S9083; considered a covered service.

12/15/03

Revised description and when services are covered sections. Added A4538, G0252, S8460, and S8990. Deleted S9806 (2004 HCPCS Update) and V5273. Deleted codes that have a guideline. Updated references. Added program exception for Medicare & More. On 01/14/04: deleted S8030.

01/22/04

Added code E0245.

04/01/04

Added code S0618.

04/15/04

Deleted codes 97802, 97803, 97804, G0270, G0271 and S9470.

10/15/04

Deleted G0237, G0238, and G0239. Deleted code 50590 from cross reference section for code S0400 and replaced with “lithotripsy, extracorporeal shock wave”.

11/15/04

Added cross-reference “Refer to Member Contract” for code 99361, and 99362.

12/15/04

Reviewed; added an asterisk to the following covered codes for Medicare B: 99056, 99080, 99082, 99090, 99091, 99361, 99362, 99371, 99372, 99373, 99380, A4458, A4238, A4554, A4890, A4931, A4932, A9300, B4100, D0480, D1330, D9310, E0218, E0244, E0245, E0273, E0274, D0315, E0370, E0950, E1372, G0244, G0293, G0294, G9016, L2760, L7367, L7368, P2029, P2038, and Q3014. Revised program exception for Medicare and More; code 99375 and 99378 is considered not valid for Medicare.

01/01/05

HCPCS update; revised G0244 descriptor. Deleted A4521, A4528, A4538. Added A4520, and S2152.

04/15/05

HCPCS update; added code S0625.

05/15/05

Added CPT code 92015.

08/15/05

HCPCS update; added G0375 and G0376. Added S9075.

01/01/06

CPT update; Added 0115T, 0116T, 0117T, 0130T, 90649, 90736, 99339, 99340, A9275, A9281, L7600, G0378, G0379. Deleted G0244. Revised descriptor 99056. Added “Refer to Member Contract” for E0273.

02/15/06

Deleted HCPCS code G0378, and G0379.

06/15/06

Deleted CPT code 97036. Updated references.

07/15/06

Annual review. Added 56805 and 57335 (added program exception for Medicare Advantage products). (Added 83037. Added asterisk to codes: 99339, 99375, and 99378, A4554, G0293, and P2038). Revised CPT code S0618 and S0625 coverage section. Updated references.) Deleted 90649.

01/01/07

HCPCS update. Added codes 92025, 0173T, 0174T, 0175T, S0820, A4601, A8000, A8001, A8002, A8003, A8004, E0936, T4543, and G0182. Updated references.

04/01/07

HCPCS update. Deleted S0820.

09/15/07

Reformatted guideline.

11/15/07

Deleted CPT code 88380. Updated references.

01/01/08

HCPCS update. Deleted CPT codes 0115T, 0116T, 0117T, 99361, 99362, 99371, 99372, 99373, G0375, and G0376. Added CPT codes 90650, 90661, 90662, 90663, 90681, 90696, 99605, 99606, 99607, 99366, 99367, 99368, 99441, 99442, 99443, 0185T and A9283.

02/15/08

Added CPT code 93760, and 93762.

05/15/08

Deleted CPT code 90681.

07/01/08

Added CPT code 90738.

07/15/08

Deleted CPT code 90696. Updated references and related Internet links.

10/15/08

Deleted 99091, A4554, A4890, B1400, E0936, S0199, S0207, S0208, S0209, S0215, S0500, S0504, S0506, S0508, S0510, S0512, S0514, S0516, S0518, S0580, S0581, S0590, S0592, S0800, S0810, S2150, S2202, S4011, and S8190.

04/02/09

Deleted CPT code 90738.

04/21/09

Deleted CPT code 56805, 57335, 92025, 0173T, 0174T, and 0175T.

07/01/09

HCPCS 3rd quarter coding update: Added CPT code 90670.

08/01/09

Added CPT codes: 90379, and 99060. Added HCPCS codes: A4218, A4281, A4283, A4284, A4285, A4286, A4633, A4634, E0170, E0171, E0175, E0200, E0203, E0205, E0215, E0217, E0220, E0225, E0230, E0238, E0239, E0241, E0242, E0243, E0246, E0249, E0265, E0266, E0270, E0296, E0297, E0571, E0602, E0603, E0604, E0636, E0641, E0705, E1031, E1035, E1310, E1902, E8000, E8001, E8002, G0406, G0407, G0408, L6621, S8270, S9472, V2600, V2610, V2615, V2744, V2750, and V7260.

09/15/09

Deleted CPT code 90738.

11/15/09

Deleted HCPCS codes E0265, E0266, E0270, E0273, E0274, E0296, E0297, and E0315. Delete CPT code 90650. Add HCPCS codes A4244, A4245, A4246, A4247, A 4248, A4554, A4660, A4663, A4670, A4927, A6402, A6403, A6404, E0210, and E1639.

01/01/10

Annual HCPCS coding update: added HCPCS codes A4456, A4466, and E1036; deleted CPT 90379, add CPT code 90644; revise descriptors for HCPCS codes E0249 and E1035.

02/15/10

Add CPT codes 98966, 98967, and 98968.

03/15/10

Deleted CPT codes 90662 and 90670.

04/15/10

Deleted HCPCS code S0173.

05/15/10

Delete CPT codes 93760 & 93761. Add CPT code 92065, and HCPCS codes E0639 & E0640.

07/01/10

3rd quarter HCPCS update: added codes G0428 and G0429.

08/15/10

Revised coverage statement for codes S0012, S0014, S0088, S0090, S0104, S0106, S0108, S00156, S0170, S0172, S0175, S0176, S0177, S0179, S0182, and S0187 to “Refer to Member Contract”.

01/01/11

Annual HCPCS coding update. Added code A9273. Deleted codes 0130T, E0220, E0230, and E0238.

01/15/11

CPT coding update; added 90654.

07/01/11

3rd quarter HCPCS coding update. Deleted HCPCS code S9075.

08/15/11

CPT coding update; deleted 90654.

12/15/11

Deleted codes L7367 and L7368.

01/01/12

Annual HCPCS coding update. Added E0642, S8130, S8131. Revised 90644, E0641, G0406, G0407, G0408 and S9900 descriptors. Deleted E0571 and S0625.

02/15/12

Deleted codes S8130 and S8131; coverage is addressed in MCG 02-61000-04, Transcutaneous Electric Nerve Stimulation (TENS).

04/01/12

Added HCPCS codes S0353 and S0354.

06/01/12

Deleted code E0602; covered for all lines of business except Medicare Advantage. This device remains non-covered for Medicare Advantage lines of business.

08/15/12

Deleted CPT code 90644.

01/01/13

Annual CPT/HCPCS coding update. Added 90653, 90685, 90686, 90687, 90688, 90739, S9110, V5281, V5282, V5283, V5284, V5285, V5286, V5287, V5288, V5289 and V5290. Revised code descriptors for 99375, 99378, 99380, 99441, 99442 and 99443. Deleted S9109.

03/15/13

Added asterisks (*) for codes G0406, G0407 and G0408.

04/15/13

Deleted code S9443.

06/15/13

Revision. Description and Program Exception sections updated; all asterisks (*) removed. Deleted E8000, E8001, E8002.

07/01/13

Deleted codes 90685 and 90686.

09/15/13

Revision; added code S9443. Deleted code 90688.

12/15/13

Deleted code E0603 (covered per Federal mandate effective 10/01/13).

01/01/14

Annual CPT/HCPCS update. Added 99446, 99447, 99448, 99449; revised T4543 code descriptor; deleted 0185T.

07/01/14

Deleted code 90687.

11/15/14

Deleted code 90661.

01/01/15

Annual CPT/HCPCS update. Added code S9901, 90697; revised code descriptor for A4601.

07/01/15

Quarterly CPT/HCPCS update. Revised code descriptors for 90653, 90739.

11/15/15

Deleted code E0217. Refer to MCG 09-E0000-53, Cooling and Heating Devices Used in the Outpatient Setting.

01/01/16

Deleted codes S0353, 98966, 98967, 98968. Annual CPT/HCPCS update: added code 90625.

02/15/16

Deleted code 90653.

06/15/16

Deleted codes 99441, 99442, 99443, A4670, and S9443.

08/15/16

Deleted code 90625.

01/01/17

Annual CPT/HCPCS update. Added A4467, A4553, A9285, A9286, G0508, G0509, 90682, 90750, 97169, 97170, 97171, 97172. Deleted A4466, 90697, 90739, 97005, 97006.

03/15/17

Deleted 90682.

04/11/17

Deleted S0255.

04/20/17

Deleted code L2760. Deleted codes 55970 and 55980 (refer to MCG 02-55900-01, Gender Reassignment Surgery).

05/15/17

Revision; added clarifying language to Description section regarding member contracts.

07/01/17

Quarterly CPT/HCPCS update. Added code 90587.

08/15/17

Deleted code S3620.

Date Printed: August 18, 2017: 10:31 AM