The code lists in the article help explain which services (procedures) the related LCD applies to, the diagnosis codes for which the service is covered, or for which the service is not considered reasonable and necessary and therefore not covered. Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. Whooping cough due to Bordetella pertussis without pneumonia, Whooping cough due to Bordetella pertussis with pneumonia, Whooping cough due to Bordetella parapertussis without pneumonia, Whooping cough due to Bordetella parapertussis with pneumonia, Whooping cough due to other Bordetella species without pneumonia, Whooping cough due to other Bordetella species with pneumonia, Whooping cough, unspecified species without pneumonia, Whooping cough, unspecified species with pneumonia, Nonpneumonic Legionnaires' disease [Pontiac fever], SARS-associated coronavirus as the cause of diseases classified elsewhere, Other coronavirus as the cause of diseases classified elsewhere, Acute upper respiratory infection, unspecified, Influenza due to identified novel influenza A virus with pneumonia, Influenza due to identified novel influenza A virus with other respiratory manifestations, Influenza due to identified novel influenza A virus with gastrointestinal manifestations, Influenza due to identified novel influenza A virus with other manifestations, Influenza due to other identified influenza virus with the same other identified influenza virus pneumonia, Influenza due to other identified influenza virus with other specified pneumonia, Influenza due to other identified influenza virus with other respiratory manifestations, Influenza due to other identified influenza virus with gastrointestinal manifestations, Influenza due to other identified influenza virus with encephalopathy, Influenza due to other identified influenza virus with myocarditis, Influenza due to other identified influenza virus with otitis media, Influenza due to other identified influenza virus with other manifestations, Influenza due to unidentified influenza virus with specified pneumonia, Influenza due to unidentified influenza virus with other respiratory manifestations, Influenza due to unidentified influenza virus with gastrointestinal manifestations, Influenza due to unidentified influenza virus with encephalopathy, Influenza due to unidentified influenza virus with myocarditis, Influenza due to unidentified influenza virus with otitis media, Influenza due to unidentified influenza virus with other manifestations, Pneumonia due to SARS-associated coronavirus, Pneumonia due to coronavirus disease 2019, Pneumonia due to Streptococcus pneumoniae, Pneumonia due to staphylococcus, unspecified, Pneumonia due to Methicillin susceptible Staphylococcus aureus, Pneumonia due to Methicillin resistant Staphylococcus aureus, Pneumonia due to other specified bacteria, Pneumonia due to other specified infectious organisms, Hypostatic pneumonia, unspecified organism, Acute bronchitis due to Mycoplasma pneumoniae, Acute bronchitis due to Hemophilus influenzae, Acute bronchitis due to parainfluenza virus, Acute bronchitis due to respiratory syncytial virus, Acute bronchitis due to other specified organisms, Unspecified acute lower respiratory infection, Chronic obstructive pulmonary disease with (acute) lower respiratory infection, Chronic obstructive pulmonary disease with (acute) exacerbation, Mild persistent asthma with (acute) exacerbation, Mild persistent asthma with status asthmaticus, Moderate persistent asthma with (acute) exacerbation, Moderate persistent asthma with status asthmaticus, Severe persistent asthma with (acute) exacerbation, Severe persistent asthma with status asthmaticus, Unspecified asthma with (acute) exacerbation, Unspecified asthma with status asthmaticus, Encounter for observation for suspected exposure to other biological agents ruled out, Contact with and (suspected) exposure to COVID-19, Contact with and (suspected) exposure to other viral communicable diseases, Cholera due to Vibrio cholerae 01, biovar cholerae, Cholera due to Vibrio cholerae 01, biovar eltor, Enteropathogenic Escherichia coli infection, Enterotoxigenic Escherichia coli infection, Enteroinvasive Escherichia coli infection, Enterohemorrhagic Escherichia coli infection, Enterocolitis due to Clostridium difficile, recurrent, Enterocolitis due to Clostridium difficile, not specified as recurrent, Other specified bacterial intestinal infections, Bacterial intestinal infection, unspecified, Foodborne Clostridium perfringens [Clostridium welchii] intoxication, Foodborne Vibrio parahaemolyticus intoxication, Acute gastroenteropathy due to Norwalk agent, Acute gastroenteropathy due to other small round viruses, Infectious gastroenteritis and colitis, unspecified, Infection-associated hemolytic-uremic syndrome, Crohn's disease of small intestine with abscess, Crohn's disease of large intestine with abscess, Crohn's disease of both small and large intestine with abscess, Crohn's disease, unspecified, with abscess, Ulcerative (chronic) pancolitis with abscess, Ulcerative (chronic) proctitis with abscess, Ulcerative (chronic) rectosigmoiditis with abscess, Inflammatory polyps of colon with abscess, Ulcerative colitis, unspecified with abscess, Right upper quadrant abdominal tenderness, Right lower quadrant abdominal tenderness, Right upper quadrant rebound abdominal tenderness, Left upper quadrant rebound abdominal tenderness, Right lower quadrant rebound abdominal tenderness, Left lower quadrant rebound abdominal tenderness, Rebound abdominal tenderness, unspecified site, Acute paralytic poliomyelitis, vaccine-associated, Acute paralytic poliomyelitis, wild virus, imported, Acute paralytic poliomyelitis, wild virus, indigenous, Acute paralytic poliomyelitis, unspecified, Varicella encephalitis and encephalomyelitis, Human immunodeficiency virus [HIV] disease, Gammaherpesviral mononucleosis with meningitis, Cytomegaloviral mononucleosis with meningitis, Other infectious mononucleosis with meningitis, Postinfectious acute disseminated encephalitis and encephalomyelitis (postinfectious ADEM), Postimmunization acute disseminated encephalitis, myelitis and encephalomyelitis, Acute necrotizing hemorrhagic encephalopathy, unspecified, Postinfectious acute necrotizing hemorrhagic encephalopathy, Postimmunization acute necrotizing hemorrhagic encephalopathy, Other acute necrotizing hemorrhagic encephalopathy, Encephalitis and encephalomyelitis, unspecified, Encephalitis and encephalomyelitis in diseases classified elsewhere, Myelitis in diseases classified elsewhere, Sepsis due to Methicillin susceptible Staphylococcus aureus, Sepsis due to Methicillin resistant Staphylococcus aureus, Sepsis due to other specified staphylococcus, Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene, Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene, Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene, Acute and subacute infective endocarditis, Fever presenting with conditions classified elsewhere, Bloodstream infection due to central venous catheter, initial encounter, Bloodstream infection due to central venous catheter, subsequent encounter, Bloodstream infection due to central venous catheter, sequela, Other infection due to central venous catheter, initial encounter, Other infection due to central venous catheter, subsequent encounter, Other infection due to central venous catheter, sequela, Unspecified infection due to central venous catheter, initial encounter, Unspecified infection due to central venous catheter, subsequent encounter, Unspecified infection due to central venous catheter, sequela, Acute infection following transfusion, infusion, or injection of blood and blood products, initial encounter, Acute infection following transfusion, infusion, or injection of blood and blood products, subsequent encounter, Acute infection following transfusion, infusion, or injection of blood and blood products, sequela, Infection following other infusion, transfusion and therapeutic injection, initial encounter, Infection following other infusion, transfusion and therapeutic injection, subsequent encounter, Infection following other infusion, transfusion and therapeutic injection, sequela, Infection and inflammatory reaction due to cardiac valve prosthesis, initial encounter, Infection and inflammatory reaction due to cardiac valve prosthesis, subsequent encounter, Infection and inflammatory reaction due to cardiac valve prosthesis, sequela, Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, initial encounter, Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, subsequent encounter, Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, sequela, Infection and inflammatory reaction due to peritoneal dialysis catheter, initial encounter, Infection and inflammatory reaction due to peritoneal dialysis catheter, subsequent encounter, Infection and inflammatory reaction due to peritoneal dialysis catheter, sequela, Infection and inflammatory reaction due to insulin pump, initial encounter, Infection and inflammatory reaction due to insulin pump, subsequent encounter, Infection and inflammatory reaction due to insulin pump, sequela, Other genitourinary symptomatic late syphilis, Gonococcal infection of lower genitourinary tract, unspecified, Gonococcal cystitis and urethritis, unspecified, Other gonococcal infection of lower genitourinary tract, Gonococcal infection of lower genitourinary tract with periurethral and accessory gland abscess, Gonococcal infection of kidney and ureter, Gonococcal infection of other male genital organs, Gonococcal female pelvic inflammatory disease, Other gonococcal genitourinary infections, Chlamydial infection of lower genitourinary tract, unspecified, Other chlamydial infection of lower genitourinary tract, Chlamydial female pelvic inflammatory disease, Chlamydial infection of genitourinary tract, unspecified, Herpesviral infection of urogenital system, unspecified, Herpesviral infection of other male genital organs, Herpesviral infection of other urogenital tract, Herpesviral infection of perianal skin and rectum, Anogenital herpesviral infection, unspecified, Human immunodeficiency virus, type 2 [HIV 2] as the cause of diseases classified elsewhere, Other specified inflammation of vagina and vulva, Vaginitis, vulvitis and vulvovaginitis in diseases classified elsewhere, Other specified noninflammatory disorders of vagina, Human immunodeficiency virus [HIV] disease complicating pregnancy, first trimester, Human immunodeficiency virus [HIV] disease complicating pregnancy, second trimester, Human immunodeficiency virus [HIV] disease complicating pregnancy, third trimester, Adult sexual abuse, confirmed, initial encounter, Adult sexual abuse, confirmed, subsequent encounter, Adult forced sexual exploitation, confirmed, initial encounter, Adult forced sexual exploitation, confirmed, subsequent encounter, Adult forced sexual exploitation, confirmed, sequela, Adult sexual abuse, suspected, initial encounter, Adult sexual abuse, suspected, subsequent encounter, Adult forced sexual exploitation, suspected, initial encounter, Adult forced sexual exploitation, suspected, subsequent encounter, Adult forced sexual exploitation, suspected, sequela, Encounter for examination and observation following alleged adult rape, Encounter for examination and observation following alleged adult physical abuse, Encounter for examination and observation of victim following forced sexual exploitation, Encounter for screening for infections with a predominantly sexual mode of transmission, Contact with and (suspected) exposure to human immunodeficiency virus [HIV], Asymptomatic human immunodeficiency virus [HIV] infection status, Kaposi's sarcoma of gastrointestinal sites, Aplastic anemia due to other external agents, Antineoplastic chemotherapy induced pancytopenia, Other specified aplastic anemias and other bone marrow failure syndromes, Anemia due to antineoplastic chemotherapy, Agranulocytosis secondary to cancer chemotherapy, Selective deficiency of immunoglobulin A [IgA], Selective deficiency of immunoglobulin G [IgG] subclasses, Selective deficiency of immunoglobulin M [IgM], Immunodeficiency with increased immunoglobulin M [IgM], Antibody deficiency with near-normal immunoglobulins or with hyperimmunoglobulinemia, Other immunodeficiencies with predominantly antibody defects, Immunodeficiency with predominantly antibody defects, unspecified, Severe combined immunodeficiency [SCID] with reticular dysgenesis, Severe combined immunodeficiency [SCID] with low T- and B-cell numbers, Severe combined immunodeficiency [SCID] with low or normal B-cell numbers, Adenosine deaminase deficiency, unspecified, Severe combined immunodeficiency due to adenosine deaminase deficiency, Purine nucleoside phosphorylase [PNP] deficiency, Major histocompatibility complex class I deficiency, Major histocompatibility complex class II deficiency, Other biotin-dependent carboxylase deficiency, Activated Phosphoinositide 3-kinase Delta Syndrome [APDS], Immunodeficiency with short-limbed stature, Immunodeficiency following hereditary defective response to Epstein-Barr virus, Immunodeficiency associated with other specified major defects, Common variable immunodeficiency with predominant abnormalities of B-cell numbers and function, Common variable immunodeficiency with predominant immunoregulatory T-cell disorders, Common variable immunodeficiency with autoantibodies to B- or T-cells, Common variable immunodeficiency, unspecified, Lymphocyte function antigen-1 [LFA-1] defect, Acute on chronic graft-versus-host disease, Autoimmune lymphoproliferative syndrome [ALPS], Other specified disorders involving the immune mechanism, not elsewhere classified, Diabetes mellitus due to underlying condition with diabetic autonomic (poly)neuropathy, Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy, Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy, Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy, Cystic fibrosis with pulmonary manifestations, Chronic obstructive pulmonary disease, unspecified, Chronic and other pulmonary manifestations due to radiation, Interstitial lung disease with progressive fibrotic phenotype in diseases classified elsewhere, Other interstitial pulmonary diseases with fibrosis in diseases classified elsewhere, Adult pulmonary Langerhans cell histiocytosis, Other specified interstitial pulmonary diseases, Complication of immune effector cellular therapy, sequela, Encounter for antineoplastic chemotherapy, Personal history of Chimeric Antigen Receptor T-cell therapy, Personal history of other cellular therapy, Other transplanted organ and tissue status, Crohn's disease of small intestine with rectal bleeding, Crohn's disease of small intestine with intestinal obstruction, Crohn's disease of small intestine with fistula, Crohn's disease of small intestine with other complication, Crohn's disease of large intestine with rectal bleeding, Crohn's disease of large intestine with intestinal obstruction, Crohn's disease of large intestine with fistula, Crohn's disease of large intestine with other complication, Crohn's disease of both small and large intestine with intestinal obstruction, Crohn's disease of both small and large intestine with fistula, Crohn's disease of both small and large intestine with other complication, Crohn's disease, unspecified, with rectal bleeding, Crohn's disease, unspecified, with intestinal obstruction, Crohn's disease, unspecified, with fistula, Crohn's disease, unspecified, with other complication, Ulcerative (chronic) pancolitis with rectal bleeding, Ulcerative (chronic) pancolitis with intestinal obstruction, Ulcerative (chronic) pancolitis with fistula, Ulcerative (chronic) pancolitis with other complication, Ulcerative (chronic) pancolitis with unspecified complications, Ulcerative (chronic) proctitis with rectal bleeding, Ulcerative (chronic) proctitis with intestinal obstruction, Ulcerative (chronic) proctitis with fistula, Ulcerative (chronic) proctitis with other complication, Ulcerative (chronic) proctitis with unspecified complications, Ulcerative (chronic) rectosigmoiditis with rectal bleeding, Ulcerative (chronic) rectosigmoiditis with intestinal obstruction, Ulcerative (chronic) rectosigmoiditis with fistula, Ulcerative (chronic) rectosigmoiditis with other complication, Ulcerative (chronic) rectosigmoiditis with unspecified complications, Inflammatory polyps of colon with rectal bleeding, Inflammatory polyps of colon with intestinal obstruction, Inflammatory polyps of colon with fistula, Inflammatory polyps of colon with other complication, Inflammatory polyps of colon with unspecified complications, Left sided colitis with intestinal obstruction, Left sided colitis with other complication, Left sided colitis with unspecified complications, Other ulcerative colitis with rectal bleeding, Other ulcerative colitis with intestinal obstruction, Other ulcerative colitis with other complication, Ulcerative colitis, unspecified with rectal bleeding, Ulcerative colitis, unspecified with intestinal obstruction, Ulcerative colitis, unspecified with fistula, Ulcerative colitis, unspecified with other complication, Gastroenteritis and colitis due to radiation, Some older versions have been archived. To license the electronic data file of UB-04 Data Specifications, contact Tim Carlson at (312) 893-6816. Most DMEPOS accessory/supply items provided on a recurring basis can be dispensed with a three-month supply. CMS and the DME MACs will post on their websites the Required List of selected HCPCS codes, which will be published through the Federal Register Notice, and periodically updated. Otherwise, a separate WOPD in addition to a subsequently completed and signed CMN is necessary. Only one (1) unit of service (equals one bilateral injection. If your session expires, you will lose all items in your basket and any active searches. Self-Administered Drug (SAD) Exclusion List articles list the CPT/HCPCS codes that are excluded from coverage under this category. file/product is with CMS and no endorsement by the AMA is intended or implied. ( 03/11/2021: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. Coders assign a code for every service or procedure a provider performs. In the therapeutic phase (after the diagnostic phase is completed), the frequency should be two months or longer between each injection, provided that there is initial pain relief with diagnostic injections of greater than or equal to (>/=) 75% - 100% with the ability to perform previously painful maneuvers, and a persistent pain relief of greater than or equal to (>/=) 50% with the continued ability to perform previously painful maneuvers is maintained for at least six weeks. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. Reimbursement shall be based on the specific utilization amount that is supported by contemporaneous medical records. Coders assign a code for every service or procedure a provider performs. CMS believes that the Internet is The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. The document is broken into multiple sections. (TTY: 711) or email us. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. 11/16/2017: At this time 21st Century Cures Act applies to new and revised LCDs that restrict coverage, which require comment and notice. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. Applicable Federal Acquisition Regulation Clauses (FARS)/Department of Defense Federal Acquisition Regulation supplement (DFARS) Restrictions Apply to Government Use. By clicking on I Accept, I acknowledge and accept that: The Applied Behavior Analysis (ABA) Medical Necessity Guidehelps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. The ABA Medical Necessity Guidedoes not constitute medical advice. Aetna's conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna). Neither the United States Government nor its employees represent that use of such information, product, or processes The suppliers record must be linked to the delivery service record by some clear method like the delivery services package identification number or suppliers invoice number for the package sent to the beneficiary. Unusual events occurred. Given the vast number of services and procedures, the AMA has organized CPT codes logically, beginning with 60.15 - Billing Requirements for CMS - Approved Clinical Trials and Coverage With Evidence 120 - Radiology or Other Diagnostic Unlisted Service or Procedure Billing Instructions for A/B MAC (A) Claims 130 - EMC Formats 140 - Bone Mass Measurements (BMMs) use of ICD codes for coding diagnostic test results is found in chapter 23. All rights reserved. Medicare contractors are required to develop and disseminate Articles. If an entity wishes to utilize any AHA materials, please contact the AHA at 312-893-6816. If you are looking for a specific code, use your browser's Find function (Ctrl-F) to quickly locate the code in the article. Evidence-based guideline: American Family Physician 2010;82(2):151-158 T. Lindsay, B. Rodgers, V. Savath, K. Hettinger. Subject to the terms and conditions contained in this Agreement, you, your employees and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. The member's benefit plan determines coverage. Added B37.31, B37.32, and N76.82. and dosage of the drug in block 19 on the CMS-1500 claim form (or in 2400.SV101-7 in the ANSI 837 claim file). Under Article Text revised first and second bullet verbiage to add or PLA and deleted third and fourth bullet verbiage. Under CPT/HCPCS Group 4: Paragraph deleted second sentence. CPT is a trademark of the American Medical Association (AMA). POD documentation must be available to the Medicare contractor on request. Since Dental Clinical Policy Bulletins (DCPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies.