Medical Policies
Coverage for services under Medicare is primarily established through the Social Security Act. Provisions of the Social Security Act are applied to specific services based on various regulations, National Coverage Determinations established by the Centers for Medicare & Medicaid Services (CMS), various CMS guidelines, and Local Coverage Determinations (LCDs) established by CGS.
- NCDs are developed by CMS to describe the circumstances for Medicare coverage nationwide for an item or service.
- LCDs are developed by Medicare Administrative Contractors (MACs), including CGS, and indicate whether a particular item or service is covered in accordance with the Social Security Act, section 1862(a)(1)(A). (See list of LCDs below.)
- NCDs and LCDs only address certain services and items; in other words, not every item or service has a corresponding NCD or LCD. In these cases, the Social Security Act, and in some cases, additional guidance published by CMS, establish the basis for coverage.
- For more information about NCDs, LCDs, and other coverage provisions, refer to the CMS Medicare Program Integrity Manual (Pub. 100-08), chapter 13
.
- CAC Compliance Open and Provider Touch Point Meetings
IMPORTANT NOTE: CGS does NOT house LCDs on our website. By following the links below you will be sent directly to the CMS Medicare Coverage Database (MCD). When using the individual links provided below there may be times that you will receive the message "superseded", indicating you are not viewing the most current LCD. This is due to system processes which cause a delay in updating these links. If you get the note "superseded" on a policy, please use the main link listed below for current LCDs to the MCD provided while we complete the process of updating the individual links.
The following CGS Part A Local Coverage Determinations (LCDs) are located on the Centers for Medicare & Medicaid Services (CMS) Medicare Coverage Database (MCD) webpage. CMS also provides the LCD Contractor Index, where providers can browse LCDs by contractor.
- Current Kentucky Part B Local Coverage Determinations
- Current Kentucky Part B Coverage Articles
- Future Kentucky Part B Local Coverage Determinations
- Draft Kentucky Part B Local Coverage Determinations
- Current Ohio Part B Local Coverage Determinations
- Current Ohio Part B Coverage Articles
- Future Ohio Part B Local Coverage Determinations
- Draft Ohio Part B Local Coverage Determinations
- Medicare Coverage Database Archived Local Coverage Determinations
- SE1421 How to Access Updates to ICD-10 Local Coverage Determinations in the CMS Medicare Coverage Database
ID | Title / ID | Effective Date | Revision Effective Date | Last Updated | Status | HCPC/CPT code | Related Policy Article(s) |
---|---|---|---|---|---|---|---|
L32553![]() |
Allergy Immunotherapy | 10/1/15 | 11/7/19 | 10/29/19 | Active | 95115, 95117, 95144, 95145, 95146, 95147, 95148, 95149, 95165, 95170, 95180, 95199 | A56424 – Billing and Coding: Allergy Immunotherapy![]() |
L33943![]() |
B-type Natriuretic Peptide (BNP) Testing | 10/1/15 | 11/28/19 | 11/25/19 | Active | 83880 | A56425 – Billing and Coding: B-type Natriuretic Peptide (BNP) Testing![]() |
L36975![]() |
Bladder/Urothelial Tumor Markers | 3/6/17 | 10/31/19 | 1/24/20 | Active | 86294, 86316, 86386, 88120, 88121 | A56471 – Billing and Coding: Bladder / Urothelial Tumor Markers ![]() |
L33944![]() |
Blepharoplasty | 10/1/15 | 11/7/19 | 10/30/19 | Active | Group 1: 67909, 67911, 67914 ,67915, 67916, 67917, 67921, 67922, 67923, 67924 Group 2: 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906 ,67908 |
A56439 – Billing and Coding: Blepharoplasty![]() |
L36460![]() |
Bone Mass Measurement | 2/1/16 | 12/26/19 | 12/20/19 | Active | 76977, 77078, 77080, 77081, 77085, 78350, 78351, G0130, 0508T, 0554T, 0555T, 0556T, 0557T, 0558T | A57132 – Billing and Coding: Bone Mass Measurement![]() |
L33949![]() |
Botulinum Toxins | 10/1/15 | 11/28/19 | 11/25/19 | Active | Group 1: 43201, 43236, 46505, 52287, 64611, 64612, 64615, 64616, 64617, 64642, 64643, 64644, 64645, 64646, 64647, 64650, 64653, 67345 Group 2: C9399, J0585, J0586, J0587, J0588, J3590 |
A56472 – Billing and Coding: Botulinum Toxins![]() |
L33950![]() |
Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography | 10/1/15 | 11/28/19 | 11/25/19 | Active | 77065, 77066, 77067 | A56448 – Billing and Coding: Breast Imaging Mammography / Breast Echography (Sonography) / Breast MRI / Ductography![]() |
L33946![]() |
Capsule Opacification Following Cataract Surgery: Discission and YAG Laser Capsulotomy | 10/1/15 | 11/7/19 | 10/30/19 | Active | 66820, 66821 | A56493 – Billing and Coding: Capsule Opacification Following Cataract Surgery: Discission and YAG Laser Capsulotomy![]() |
L33959![]() |
Cardiac Catheterization and Coronary Angiography | 10/1/15 | 11/7/19 | 10/30/19 | Active | Group 1:
92978, 92979, 93451, 93452, 93453, 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, 93462, 93463, 93464, 93503, 93505 ,93530 ,93531 ,93532 ,93533, 93561, 93562, 93563, 93564, 93565, 93566 ,93567, 93568 , 93571 , 93572 , G0269 Group 2: 36140, 36200, 36215, 36216, 36217, 36218, 36221, 36222, 36223, 36224, 36225, 36226, 36227, 36228, 36245, 36246, 36247, 36248, 75625, 75630, 75635, 75705, 75710, 75716 Group 3: G0278 |
A56500 – Billing and Coding: Cardiac Catheterization and Coronary Angiography ![]() |
L33947![]() |
Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA) | 10/1/15 | 9/19/19 | 10/30/19 | Active | 75571, 75572, 75573, 75574 | A56451 – Billing and Coding: Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA) ![]() |
L33952![]() |
Cardiac Event Detection | 10/1/15 | 9/19/19 | 11/25/19 | Active | 93228, 93229, 93268,93270, 93271 ,93272, 93799 | A56452 – Billing and Coding: Cardiac Event Detection ![]() |
L33960![]() |
Cardiovascular Nuclear Medicine | 10/1/15 | 9/19/19 | 1/24/20 | Active | 78451, 78452, 78453, 78454, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78494, 78496, 93015, 93016, 93017, 93018, A9500, A9501, A9502, A9505, A9512, A9538, A9560, J0153, J1245, J1250, J2785, J3490 | A56494 – Billing and Coding: Cardiovascular Nuclear Medicine ![]() |
L33954![]() |
Cataract Extraction | 10/1/15 | 12/16/16 | 12/20/19 | Active | 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984 | A56453 – Billing and Coding: Cataract Extraction ![]() |
L34370![]() |
Category III CPT® Codes | 10/1/15 | 12/26/19 | 12/20/19 | Active | Group 1: NA Group 2: 0295T, 0296T, 0297T, 0298T Group 3: 0308T |
A54327 – Billing and Coding: ArgusM II Retinal Prosthesis System A57230 – Billing and Coding: Category III CPT® Codes ![]() |
L33945![]() |
Cerumen (Earwax) Removal | 10/1/15 | 9/19/19 | 1/24/20 | Active | 69209, 69210, G0268 | A56454 – Billing and Coding: Cerumen (Earwax) Removal ![]() |
L34093![]() |
Chemotherapy and Biologicals | 10/1/15 | 10/3/19 | 9/25/19 | Active | ||
L37254![]() |
Chiropractic Services | 11/6/17 | 9/19/19 | 9/19/19 | Active | 98940, 98941, 98942 | A56456 – Billing and Coding: Colonoscopy / Sigmoidoscopy / Proctosigmoidoscopy ![]() |
L37126![]() |
Coenzyme Q10 (CoQ10) | 7/10/17 | 9/19/19 | 12/27/19 | Active | 82542 | A55715 – Billing and Coding: Coenzyme Q10 (CoQ10) ![]() |
L34005![]() |
Colonoscopy/Sigmoidoscopy/ Proctosigmoidoscopy | 10/1/15 | 9/19/19 | 1/24/20 | Active | 44388, 44389, 44390, 44391, 44392, 44394, 44401, 44402, 45300, 45303, 45305, 45307, 45308, 45309, 45315, 45317, 45320, 45321, 45327, 45330, 45331, 45332, 45333, 45334, 45335, 45337, 45338, 45340, 45341, 45342, 45346, 45347, 45378, 45379, 45380, 45381, 45382, 45384, 45385, 45386, 45388, 45389, 45391, 45392, 45399 | A56456 – Billing and Coding: Colonoscopy / Sigmoidoscopy / Proctosigmoidoscopy![]() |
L34008![]() |
Computerized Corneal Topography | 10/1/15 | 9/19/19 | 1/28/20 | Active | 92025 | A56816 – Billing and Coding: Computerized Corneal Topography![]() |
L36029![]() |
Controlled Substance Monitoring and Drugs of Abuse Testing | 10/5/15 | 11/21/19 | 11/15/19 | Active | 80305, 80306, 80307, G0480, G0481, G0482, G0483, G0659, 0143U, 0144U, 0145U, 0146U, 0147U, 0148U, 0149U, 0150U | A56818 – Billing and Coding: Controlled Substance Monitoring and Drugs of Abuse Testing![]() |
L33999![]() |
Corneal Pachymetry | 10/1/15 | 9/19/19 | 1/28/20 | Active | 76514 | A56457 – Billing and Coding: Billing and Coding for Corneal Pachymetry![]() |
L34032![]() |
Debridement Services | 10/1/15 | 9/12/19 | 1/28/20 | Active | 11000, 11001, 11042, 11043, 11044, 11045, 11046, 11047 | A56459 – Billing and Coding: Debridement Services![]() |
L34062![]() |
Dialysis Access Maintenance | 10/1/15 | 9/19/19 | 1/28/20 | Active | 36005, 36010, 36140, 36215, 36216, 36217, 36218, 36245, 36246, 36247, 36593, 36831, 36832, 36833, 36901, 36902, 36903, 36904, 36905, 36906, 36907, 37186, 37211, 37212, 37213, 37214, 37236, 37237, 37246, 37247, 37248, 37249, 75710, 75820, 75822, 75825, 75827, 93990 | A56460 – Billing and Coding: Dialysis Access Maintenance![]() |
L34081![]() |
Endoscopy by Capsule | 10/1/15 | 9/19/19 | 2/28/20 | Active | Group 1: 91110 Group 2: 91111, 91299 |
A56461 – Billing and Coding: Endoscopy by Capsule![]() |
L34356![]() |
Erythropoiesis Stimulating Agents (ESA) | 10/1/15 | 10/3/19 | 2/24/20 | Active | J0881, J0882, J0885, J0890. Q4081, Q5105, Q5106 | A56462 – Billing and Coding: Erythropoiesis Stimulating Agents (ESA)![]() |
L34832![]() |
Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy | 10/1/15 | 12/26/19 | 12/20/19 | Active | 64490, 64491, 64492, 64493, 64494, 64495, 64633, 64634, 64635, 64636 | A56463 – Billing and Coding: Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy![]() |
L34037![]() |
Flow Cytometry | 10/1/15 | 10/1/19 | 2/24/20 | Active | Group 1: 88182, 88184, 88185, 88187, 88188, 88189 Group 2: 86355, 86356, 86357, 86359, 86360, 86361, 86367 |
A56464 – Billing and Coding: Flow Cytometry![]() |
L37575 ![]() |
Frequency of Hemodialysis | 4/1/19 | 10/1/19 | 1/28/20 | Active | 90999 | A56159 – Billing and Coding: Frequency of Hemodialysis![]() |
L36906![]() |
GlycoMark Testing for Glycemic Control | 3/6/17 | 10/31/19 | 3/25/20 | Active | 84378, 84999 | A56465 – Billing and Coding: GlycoMark Testing for Glycemic Control![]() |
L34089![]() |
Human Papillomavirus (HPV) Testing | 10/1/15 | 9/19/19 | 3/25/20 | Active | 87623, 87624 | A56466 – Billing and Coding: Human Papillomavirus (HPV) Testing![]() |
L35891![]() |
Intravenous Immune Globulin | 10/1/15 | 9/19/19 | 3/25/20 | Active | J1459, J1556, J1557, J1561, J1566, J1568, J1569, J1572 | A56779 – Billing and Coding: Intravenous Immune Globulin![]() |
L34090![]() |
Laser Ablation of the Prostate | 10/1/15 | 9/19/19 | 3/25/20 | Active | 52647, 52648, 52649 | A56467 – Billing and Coding: Laser Ablation of the Prostate![]() |
L34807![]() |
Lumbar Epidural Steroid Injections (ESI) | 10/1/15 | 12/26/19 | 12/20/19 | Active | 62323, 62327, 64483, 64484 | A56469 – Billing and Coding: Lumbar Epidural Steroid Injections (ESI)![]() |
L37790![]() |
Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor | 10/1/18 | 9/19/19 | 9/23/19 | Active | 0398T | A56470 – Billing and Coding: Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor![]() |
L37578![]() |
Micro-Invasive Glaucoma Surgery (MIGS) | 3/19/18 | 12/30/18 | 3/25/20 | Active | Group 1: 0191T Group 2: 0449T Group 3: 0253T, 0376T, 0450T, 0474T |
A56491 – Billing and Coding: Micro-Invasive Glaucoma Surgery (MIGS)![]() |
L36494![]() |
Minimally-Invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint | 2/1/16 | 12/26/19 | 12/20/19 | Active | 27279 | A56535 – Billing and Coding: Minimally-Invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint![]() |
L34195![]() |
Mohs Micrographic Surgery | 10/1/15 | 8/8/19 | 9/13/19 | Active | 17311, 17312, 17313, 17314, 17315 | A56836 – Billing and Coding: Mohs Micrographic Surgery![]() |
L36979![]() |
MolDX: 4Kscore Assay | 3/13/17 | 10/31/19 | 11/25/19 | Active | 81539 | A56944 – Billing and Coding: MolDX: 4Kscore Assay![]() |
L37362![]() |
MolDX: AlloSure® Donor-Derived Cell-Free DNA Test | 3/6/18 | 10/31/19 | 1/23/20 | Active | 81479 | A57032 – Billing and Coding: MolDX: AlloSure® Donor-Derived Cell-Free DNA Test![]() |
L36910![]() |
MolDX: APC and MUTYH Gene Testing | 3/13/17 | 11/28/19 | 11/21/19 | Active | Group 1: 81201, 81202, 81203 , 81479 Group 2: 81401, 81403, 81406, 81435, 81436 Group 3: 0157U |
A56828 – Billing and Coding: MolDX: APC and MUTYH Gene![]() |
L37134![]() |
MolDX: BDX-XL2 | 7/10/17 | 10/24/19 | 10/17/19 | Active | 0080U | A56947 – Billing and Coding: MolDX: BDX-XL2![]() |
L36139![]() |
MolDX: Biomarkers in Cardiovascular Risk Assessment | 10/5/15 | 11/14/19 | 11/5/19 | Active | 81439, 82172, 82610, 83090, 83695, 83698, 83700, 83701, 83704, 83719, 83721, 86141 | A54685 – Billing and Coding: MolDX: Arrhythmogenic Right Ventricular Dysplasia / Cardiomyopathy (ARVD / C) Testing Coding and Billing Guidelines![]() A57386 – Billing and Coding: MolDX: Biomarkers in Cardiovascular Risk Assessment ![]() |
L36456![]() |
MolDX: BRCA1 and BRCA2 Genetic Testing | 2/15/16 | 1/9/20 | 12/31/19 | Active | Group 1: 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, 81217, 81432, 81433, 81479, 0102U, 0103U, 0129U Group 2: 0131U, 0132U, 0133U, 0134U, 0135U, 0136U, 0137U, 0138U, 0157U, 0158U, 0159U, 0160U, 0161U, 0162U Group 3: 81162, 81445, 81455 |
A56971 – Billing and Coding: MolDX: BRCA1 and BRCA2 Genetic Testing![]() A54689 – Billing and Coding: MolDX: Myriad’s BRACAnalysis CDx™ ![]() |
L36425![]() |
MolDX: Breast Cancer Assay: Prosigna | 2/1/16 | 9/23/19 | 11/15/19 | Active | 81520 | A56989 – Billing and Coding: MolDX: Breast Cancer Assay: Prosigna![]() |
L37832![]() |
MolDX: Breast Cancer™ (BCI) Gene Expression Test | 4/1/19 | 10/31/19 | 4/30/20 | Active | 81518 | A56884 – Billing and Coding: MolDX: Breast Cancer Index™ (BCI) Gene Expression Test![]() |
L36006![]() |
MolDX-CDD: ConfirmMDx Epigenetic Molecular Assay | 10/5/15 | 11/7/19 | 10/28/19 | Active | 81551 | A57031 – Billing and Coding: MolDX: ConfirmMDx Epigenetic Molecular Assay![]() |
L36675![]() |
MolDX - CDD: ProMark Risk Score | 10/10/16 | 11/28/19 | 11/21/19 | Active | 81479 | A57034 – Billing and Coding: MolDX- CDD: ProMark Risk Score![]() |
L36973![]() |
MolDX: Circulating Tumor Cell Marker Assays | 3/6/17 | 11/7/19 | 3/25/20 | Active | 86152, 86153 | A57288 – Billing and Coding: MolDX: Circulating Tumor Cell Marker Assays![]() |
L37787![]() |
MolDX: Corus® CAD Assay | 11/12/18 | 9/19/19 | 11/25/19 | Active | 81493 | A56950 – Billing and Coding: MolDX: Corus® CAD Assay![]() |
L35332![]() |
MolDX: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing | 10/1/15 | 9/23/19 | 10/17/19 | Active | Group 1: 81225 Group 2: 81226, 0070U Group 3: 81227, 81355 Group 4: 81479 |
A56864 – Billing and Coding: MolDX: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing ![]() |
L37598![]() |
MolDX: Cystatin C Measurement | 12/17/18 | 11/28/19 | 12/27/19 | Active | 82610 | A56988 – Billing and Coding: MolDX: Cystatin C Measurement![]() |
L37834![]() |
MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease | 4/29/19 | 1/9/20 | 3/25/20 | Active | 81542 | A56984 – Billing and Coding: MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease![]() |
L36656![]() |
MolDX: Decipher® Prostate Cancer Classifier Assay | 10/10/16 | 11/14/19 | 11/25/19 | Active | 81542 | A56992 – Billing and Coding: MolDX: Decipher® Prostate Cancer Classifier Assay ![]() |
L38016![]() |
MolDX: DecisionDx-Melanoma | 6/24/19 | 10/3/19 | 9/26/19 | Active | 81599 | A56990 – Billing and Coding: MolDX: DecisionDx-Melanoma ![]() |
L37130![]() |
MolDX: DecisionDx-UM (Uveal Melanoma) | 7/10/17 | 10/31/19 | 12/27/19 | Active | 81552 | A56981 – Billing and Coding: MolDX: DecisionDx-UM (Uveal Melanoma)![]() |
L37356![]() |
MolDX: EndoPredict Breast Cancer Gene Expression Test | 3/6/18 | 11/14/19 | 11/8/19 | Active | 81522 | A56997 – Billing and Coding: MolDX: EndoPredict Breast Cancer Gene Expression Test![]() |
L37905![]() |
MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test | 5/20/19 | 11/7/19 | 2/28/20 | Active | 81479 | A56985 – Billing and Coding: MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test![]() |
L37364![]() |
MolDX: Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification Tests (NAATs) | 1/7/19 | 11/28/19 | 11/21/19 | Active | Group 1: 87505, 87506, 0097U Group 2: 87507 |
A56596 – Billing and Coding: Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification (NAATs) ![]() |
L35443![]() |
MolDX: GeneSight Assay for Refractory Depression | 10/1/15 | 11/28/19 | 11/21/19 | Active | 81479 | A56936 – Billing and Coding: MolDX: GeneSight® Assay for Refractory Depression![]() |
L36117![]() |
MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease | 10/5/15 | 12/19/19 | 12/13/19 | Active | Group 1: 81206, 81207, 81208, 81219, 81270, 81402, 81479, 0040U Group 2: 81403, 81445, 81450, 81455 |
A54686 – Billing and Coding: MolDX: BCR-ABL ![]() A56999 – Billing and Coding: MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease ![]() |
L35984![]() |
MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR) | 10/1/15 | 10/31/15 | 10/23/19 | Active | 81240, 81241, 81291 | A56980 – Billing and Coding: MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR)![]() |
L35349![]() |
MolDX: Genetic Testing for Lynch Syndrome | 10/1/15 | 12/5/19 | 12/31/19 | Active | Group 1: 81210, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81317, 81318, 81319, 81479, 88341,88342, 0101U Group 2: 81445, 81455, 0130U, 0134U, 0157U, 0158U, 0159U, 0160U, 0161U, 0162U Group 3: 81301, 81403, 81435, 81436 |
A56882 – Billing and Coding: MolDX: Genetic Testing for Lynch Syndrome![]() A56106 – Billing and Coding: MolDX: Microsatellite Instability-High (MSI-H) and Mismatch Repair Deficient (dMMR) Biomarker for Patients with Unresectable or Metastatic Solid Tumors ![]() |
L36206![]() |
MolDX: Genomic Health® Oncotype DX® Prostate Cancer Assay | 10/5/15 | 11/14/19 | 11/4/19 | Active | 0047U | A56976 – Billing and Coding: MolDX: Genomic Health™ Oncotype DX® Prostate Cancer Assay![]() |
L36048![]() |
MolDX: HLA-B*15:02 Genetic Testing | 10/5/15 | 11/7/19 | 10/28/19 | Active | 81381 | A56979 – Billing and Coding: MolDX: HLA-B*15:02 Genetic Testing![]() |
L36485![]() |
MolDX: HLA-DQB1*06:02 Testing for Narcolepsy | 2/15/16 | 12/26/19 | 12/20/19 | Active | 81383 | A56881 – Billing and Coding: MolDX: HLA-DQB1*06:02 Testing for Narcolepsy![]() |
L37903![]() |
MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer | 5/13/19 | 3/5/20 | 3/25/20 | Active | 81479 | A56982 – Billing and Coding: MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer![]() |
L37608![]() |
MolDX: MDS FISH | 5/6/19 | 11/7/19 | 3/25/20 | Active | 88271, 88273, 88274, 88275, 88291 | A56926 – Billing and Coding: MolDX: MDS FISH![]() |
L36113![]() |
MolDX: MGMT Promoter Methylation Analysis | 10/5/15 | 11/21/19 | 12/27/19 | Active | 81287 | A56983 – Billing and Coding: MolDX: MGMT Promoter Methylation Analysis ![]() |
L36011![]() |
MolDX: Molecular RBC Phenotyping | 10/5/15 | 11/7/19 | 10/28/19 | Active | 0001U | A56986 – Billing and Coding: MolDX: Molecular RBC Phenotyping![]() |
L37348![]() |
MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels | 12/3/18 | 11/28/19 | 11/21/19 | Active | Group 1: 87631, 0098U, 0099U, 0100U, 0115U Group 2: 87632, 87633 |
A56974 – Billing and Coding: MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels![]() |
L37907![]() |
MolDX: myPath Melanoma Assay | 6/3/19 | 10/31/19 | 3/25/20 | Active | 81479, 0090U | A56878 – Billing and Coding: MolDX: myPath Melanoma Assay![]() |
L35442![]() |
MolDX: NRAS Genetic Testing | 10/1/15 | 11/28/19 | 11/21/19 | Active | 81311, 81479 | A56998 – Billing and Coding: MolDX: NRAS Genetic Testing![]() |
L37836![]() |
MolDX: Oncotype DX AR-V7 Nucleus Detect for Men with Metastatic Castrate Resistant Prostate Cancer (MCRPC) | 3/25/19 | 11/21/19 | 1/23/20 | Active | 81479 | A57003 – Billing and Coding: MolDX: Oncotype DX AR-V7 Nucleus Detect for Men with Metastatic Castrate Resistant Prostate Cancer (MCRPC) ![]() |
L36951![]() |
MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health®) | 3/6/17 | 11/28/19 | 11/21/19 | Active | 0045U | A56887 – Billing and Coding: MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™) ![]() |
L37354![]() |
MolDX: Oncotype DX® Genomic Prostate Score for Men with Favorable Intermediate Risk Prostate Cancer | 3/6/18 | 11/14/19 | 3/25/20 | Active | 0047U | A56976 – Billing and Coding: MolDX: Genomic Health™ Oncotype DX® Prostate Cancer Assay![]() |
L36908![]() |
MolDX: Percepta® Bronchial Genomic Classifier | 3/13/17 | 11/28/19 | 11/21/19 | Active | 81479 | A56972 – Billing and Coding: MolDX: Percepta® Bronchial Genomic Classifier ![]() |
L36002![]() |
MolDX: Prolaris® Prostate Cancer Genomic Assay | 10/5/15 | 11/7/19 | 10/28/19 | Active | 81541 | A57303 – Billing and Coding: MolDX: Prolaris™ Prostate Cancer Genomic Assay ![]() |
L37142![]() |
MolDX: Prolaris® Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease | 7/10/17 | 10/31/19 | 10/24/19 | Active | 81541 | A56925 – Billing and Coding: MolDX: Prolaris™ Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease![]() |
L37352![]() |
MolDX: Prometheus IBD sgi Diagnostic Policy | 11/6/17 | 11/14/19 | 11/5/19 | Active | 81479, 82397, 83520, 86140 | A56940 – Billing and Coding: MolDX: Prometheus IBD sgi Diagnostic Policy ![]() |
L36021![]() |
Molecular Diagnostic Tests (MDT) | 10/1/15 | 12/19/19 | 12/11/19 | Active | Group 1: 81105, 81106, 8110,7 81108, 81109, 81110, 81111, 81112, 81120, 81121, 81161 - 81364 81400, 81402, 81404, 81405, 81408, 81410, 81411, 81413 - 81595 81599, 84999, 85999, 86152, 86153, 86849, 87999, 0004M, 0006M, 0007M, 0011M, 0012M, 0013M, 0001U, 0003U, 0005U, 0009U, 0012U, 0013U, 0014U, 0016U, 0017U, 0018U, 0019U, 0021U, 0022U, 0023U, 0024U, 0026U, 0027U, 0029U, 0030U, 0031U, 0032U, 0033U, 0034U, 0036U, 0037U, 0039U, 0040U, 0045U - 0050U 0053U - 0060U 0062U, 0067U, 0068U, 0070U - 0076U, 0078U - 0080U 0083U, 0084U, 0087U - 0092U 0094U, 0101U - 0103U 0105U, 0107U, 0108U, 0111U, 0113U, 0114U, 0118U, 0120U, 0129U - 0132U, 0134U - 0138U, 0153U - 0162U Group 2: 81401, 81403, 80406, 81407, 81412 |
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L34171![]() |
Nasal Punctum-Nasolacrimal Duct Dilation and Probing with or without Irrigation | 10/1/15 | 9/26/19 | 9/19/19 | Active | 68801, 68810, 68811, 68815, 68816, 68840 | A57284 – Billing and Coding: Nasal Punctum-Nasolacrimal Duct Dilation and Probing with or without Irrigation![]() |
L35249![]() |
Nerve Blocks for Peripheral Neuropathy | 10/1/15 | 10/31/19 | 4/30/20 | Active | Group 1: 64450 Group 2: 76881, 76882, 76942, 76999, 97032, 97139, G0282, G0283 |
A57663 – Billing and Coding: Nerve Blocks for Peripheral Neuropathy![]() |
L35897![]() |
Nerve Conduction Studies and Electromyography | 10/1/15 | 10/24/19 | 10/15/194/30/20 | Active | 51785, 92265, 95860, 95861, 95863, 95864, 95865, 95866, 95867, 95868, 95869, 95870, 95872, 95873, 95874, 95885, 95886, 95887, 95905, 95907, 95908, 95909, 95910, 95911, 95912, 95913, 95933, 95937, 95999, G0255 | A57307 – Billing and Coding: Nerve Conduction Studies and Electromyography![]() |
L34045![]() |
Non-Invasive Vascular Studies | 10/1/15 | 11/28/19 | 11/21/19 | Active | Group 1: 93880, 93882, 93886, 93888, 93892, 93893 Group 2: 93922, 93923, 93924, 93925, 93926, 93930, 93931 Group 3: 93970, 93971 Group 4: 93975, 93976, 93978, 93979 Group 5: 93985, 93986, 93990 |
A56697 – Billing and Coding: Non-Invasive Vascular Studies![]() |
L34393![]() |
Ocular Photography - External | 10/1/15 | 10/31/19 | 10/24/19 | Active | 92285 | A57068 – Billing and Coding: Ocular Photography – External![]() |
L34175![]() |
Ophthalmic Angiography (Fluorescein and Indocyanine Green) | 10/1/15 | 10/31/19 | 10/24/19 | Active | 92235, 92240 | A57069 – Billing and Coding: Ophthalmic Angiography (Fluorescein and Indocyanine Green)![]() |
L34181![]() |
Ophthalmic Biometry for Intraocular Lens Power Calculation | 10/1/15 | 12/5/19 | 11/26/19 | Active | 76519, 92136 | A57070 – Billing and Coding: Ophthalmic Biometry for Intraocular Lens Power Calculation![]() |
L34399![]() |
Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography) | 10/1/15 | 12/5/19 | 11/27/19 | Active | 92201, 92202, 92227, 92228, 92250 | A57071 – Billing and Coding: Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)![]() |
L34049![]() |
Outpatient Physical and Occupational Therapy Services | 10/1/15 | 11/14/19 | 11/6/19 | Active | 29065, 29075, 29085, 29086, 29105, 29125, 29126, 29130, 29131, 29200 ,29240, 29260, 29280, 29345, 29355, 29365, 29405, 29425, 29445, 29505, 29515, 29520, 29530, 29540, 29550, 29580, 29799, 90901, 90912, 90913, 95851, 95852, 96125, 97010, 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97129, 97130, 97139, 97140, 97150, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97530, 97533, 97535, 97537, 97542, 97597, 97598, 97602, 97605, 97606, 97607, 97608, 97750, 97755, 97760, 97761, 97763, 97799, G0281, G0283, G0329 | A57067 – Billing and Coding: Outpatient Physical and Occupational Therapy Services![]() |
L34353![]() |
Outpatient Psychiatry and Psychology Services | 10/1/15 | 11/7/19 | 10/29/19 | Active | 90785, 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90846, 90847, 90849, 90853, 90863, 90865, 90870, 90880, 90885, 90887, 90889, 90899, 96105, 96110, 96112, 96113, 96116, 96130, 96131, 96136, 96137, 96138, 96139, 96146 | A57065 – Billing and Coding: Outpatient Psychiatry and Psychology Services![]() |
L34064![]() |
Panretinal (Scatter) Laser Photocoagulation | 10/1/15 | 10/3/19 | 2/24/20 | Active | 61882 | A56594 – Billing and Coding: Panretinal (Scatter) Laser Photocoagulation![]() |
L36902![]() |
Polysomnography and Other Sleep Studies | 3/6/17 | 9/26/19 | 9/20/19 | Active | Group 1: 95782, 95783, 95800, 95801, 95805, 95806, 95807, 95808, 95810, 95811, G0398, G0399, G0400 Group 2: 95803 |
A57049 – Billing and Coding: Polysomnography and Other Sleep Studies![]() |
L34085![]() |
Post-Void Residual Urine and/or Bladder Capacity by Ultrasound | 10/1/15 | 10/1/16 | 9/20/19 | Active | 51798 | A57050 – Billing and Coding: Post-Void Residual Urine and / or Bladder Capacity by Ultrasound![]() |
L36658![]() |
Proton Beam Therapy | 10/24/16 | 9/26/19 | 9/23/19 | Active | 77520, 77522, 77523, 77525 | A55315 – Billing and Coding: Proton Beam Therapy![]() |
L34183![]() |
Psychiatric Inpatient Hospitalization | 10/1/15 | 9/26/19 | 2/24/20 | Active | NA | A57052 – Billing and Coding: Psychiatric Inpatient Hospitalization![]() |
L34196![]() |
Psychiatric Partial Hospitalization Programs | 10/1/15 | 11/7/19 | 2/24/20 | Active | 90785, 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, 90849, 90853, 90899, 96116, 96130, 96131, 96136, 96137, 96138, 96139, 96146, G0129, G0176, G0177, G0410, G0411 | A57053 – Billing and Coding: Psychiatric Partial Hospitalization Programs![]() |
L34539![]() |
Psychological Services Coverage under the Incident to Provision for Physicians and Non-physicians | 10/1/15 | 11/28/19 | 2/24/20 | Active | 90785, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90846, 90847, 90849, 90853, 90863, 90880, 90899 | A57054 – Billing and Coding: Psychological Services Coverage under the Incident to Provision for Physicians and Non-physicians![]() |
L34063![]() |
RAST Type Tests | 10/1/15 | 12/5/19 | 11/27/19 | Active | 86001, 86003, 86005 | A57043 – Billing and Coding: RAST Type Tests![]() |
L34200![]() |
Removal of Benign Skin Lesions | 10/1/15 | 9/26/19 | 9/16/19 | Active | 11200, 11201, 11300, 11301, 11302, 11303, 11305, 11306, 11307, 11308, 11310, 11311, 11312, 11313, 11400, 11401, 11402, 11403, 11404, 11406, 11420, 11421, 11422, 11423, 11424, 11426, 11440, 11441, 11442, 11443, 11444, 11446, 17000, 17003, 17004, 17106, 17107, 17108, 17110, 17111, 17340 | A57044 – Billing and Coding: Removal of Benign Skin Lesions![]() |
L36469![]() |
Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder | 2/8/16 | 12/26/19 | 12/19/19 | Active | 90867, 90868, 90869 | A57047 – Billing and Coding: Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder![]() |
L34246![]() |
Routine Foot Care and Debridement of Nails | 10/1/15 | 11/28/19 | 11/20/19 | Active | 11055, 11056, 11057, 11719, 11720, 11721, G0127 | A57193 – Billing and Coding: Routine Foot Care and Debridement of Nails![]() |
L34061![]() |
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) | 10/1/15 | 10/3/19 | 9/23/19 | Active | 92133, 92134 | A56692 – Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)![]() |
L35906![]() |
Somatosensory Testing | 10/1/15 | 9/26/19 | 3/25/20 | Active | 95925, 95926, 95927, 95928 | A57041 – Billing and Coding: Somatosensory Testing![]() |
L35986![]() |
Special Histochemical Stains and Immunohistochemical Stains | 10/1/15 | 10/31/19 | 12/27/19 | Active | 88312, 88313, 88341, 88342, 88344, 88360, 88361 | A56536 – Billing and Coding: Special Histochemical Stains and Immunohistochemical Stains![]() |
L34046![]() |
Speech-Language Pathology | 10/1/15 | 9/26/19 | 9/20/19 | Active | 31579, 92507, 92508, 92521, 92522, 92523, 92524, 92597, 92607, 92608, 92609, 92626, 92627, 96105, 96110, 96112, 96113, 96125, 97129, 97130, 97533 | A57040 – Billing and Coding: Speech-Language Pathology![]() |
L34540![]() |
Stretta Procedure | 10/1/15 | 9/26/19 | 9/23/19 | Active | 43257 | A57039 – Billing and Coding: Stretta Procedure![]() |
L34087![]() |
Surveillance of Implantable or Wearable Cardioverter Defibrillators (ICDs): Office, Hospital, Web, or Non-Web Based | 10/1/15 | 9/26/19 | 9/23/19 | Active | 93282, 93283, 93284, 93287, 93289, 93292, 93295, 93296 | A57038 – Billing and Coding: Surveillance of Implantable or Wearable Cardioverter Defibrillators (ICDs): Office, Hospital, Web, or Non-Web Based![]() |
L34084![]() |
Transcatheter Infusion Therapy | 10/1/15 | 12/5/19 | 11/27/19 | Active | 61650, 61651 | A56811 – Billing and Coding: Transcatheter Infusion Therapy![]() |
L34337![]() |
Transesophageal Echocardiography (TEE) | 10/1/15 | 9/26/19 | 9/23/19 | Active | 76376, 76377, 93312, 93313, 93314, 93315, 93316, 93317, 93318, 93320, 93321, 93325, C8925, C8926, C8927 | A56809 – Billing and Coding: Transesophageal Echocardiography (TEE)![]() |
L34541![]() |
Transtelephonic Spirometry | 10/1/15 | 9/26/19 | 9/26/19 | Active | 94014, 94015, 94016 | A56808 – Billing and Coding: Transtelephonic Spirometry![]() |
L34338![]() |
Transthoracic Echocardiography (TTE) | 10/1/15 | 9/26/19 | 9/26/19 | Active | Group 1: 76376, 76377, 93303, 93304, 93306, 93307, 93308, 93320, 93321, 93325, 93350, 93351, 93352, A9700, C8921, C8922, C8923, C8924, C8928, C8929, C8930, Q9955, Q9956, Q9957 Group 2: C9399, J0153, J0280, J0461, J1245, J1250, J2785, J3490 |
A57306 – Billing and Coding: Transthoracic Echocardiography (TTE)![]() |
L34056![]() |
Urodynamics | 10/1/15 | 9/26/19 | 9/26/19 | Active | 51725, 51726, 51727, 51728, 51729, 51736, 51741, 51792, 51797 | A56802 – Billing and Coding: Urodynamics![]() |
L34082![]() |
Varicose Veins of the Lower Extremity, Treatment of | 10/1/15 | 9/26/19 | 9/26/19 | Active | 36465, 36466, 36468, 36470, 36471, 36475, 36476, 36478, 36479, 36482, 36483, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37799, 76942, 93970, 93971 | A57305 – Billing and Coding: Varicose Veins of the Lower Extremity, Treatment of![]() |
L34055![]() |
Virtual Colonoscopy (CT Colonography) | 10/1/15 | 9/26/19 | 9/26/19 | Active | Group 1: 74261, 74262 Group 2: 74263 |
A56800 – Billing and Coding: Virtual Colonoscopy (CT Colonography)![]() |
L34394![]() |
Visual Fields Testing | 10/1/15 | 9/26/19 | 9/26/19 | Active | 92081, 92082, 92083 | A56799 – Billing and Coding: Billing and Coding for Visual Fields Testing![]() |
L33996![]() |
Vitamin D Assay Testing | 10/1/15 | 11/28/19 | 11/20/19 | Active | 82306 | A56798 – Billing and Coding: Vitamin D Assay Testing![]() |
L36690![]() |
Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities | 10/10/16 | 10/31/19 | 10/22/19 | Active | 15002, 15003, 15004, 15005, 15040, 15050, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, C5271, C5272, C5273, C5274, C5275, C5276, C5277, C5278 | A56696 – Billing and Coding: Wound Application of Cellular and / or Tissue Based Products (CTPs), Lower Extremities![]() |
Updated: 04.09.20