ADDENDUM L								
								
LIST OF CPT1/HCPCS CODES USED TO DESCRIBE CERTAIN DESIGNATED HEALTH SERVICE CATEGORIES2 UNDER SECTION 1877 OF THE SOCIAL SECURITY ACT								
								
"Effective Date:  All codes are effective January 1, 2005."								
								
CLINICAL LABORATORY SERVICES								
								
"INCLUDE CPT codes for all clinical laboratory services in the 80000 series, except EXCLUDE CPT codes for the following blood component collection services:"								
								
86890	Autologous blood process							
86891	"Autologous blood, op salvage"							
86927	"Plasma, fresh frozen"							
86930	Frozen blood prep							
86931	Frozen blood thaw							
86932	Frozen blood freeze/thaw							
86945	Blood product/irradiation							
86950	Leukacyte transfusion							
86965	Pooling blood platelets							
86985	Split blood or products							
								
INCLUDE the following CPT and HCPCS Level II codes for other clinical laboratory services:								
								
0010T	"Tb test, gamma interferon"							
0023T	"Phenotype drug test, hiv 1"							
0026T	Measure remnant lipoproteins 							
0030T	Antiprothrombin antibody							
0041T	Detect ur infect agnt w/cpas							
0043T	Co expired gas analysis							
0058T	"Cryopreservation, ovary tiss"							
0059T	"Cryopreservation, oocyte"							
0064T	Spectroscop eval expired gas							
0085T	Breath test heart reject							
0087T	Sperm eval hyaluronan							
36415	Routine venipuncture							
G0027	Semen analysis 							
G0103	"Psa, total screening"							
G0107	CA screen; fecal blood test							
G0123	Screen cerv/vag thin layer							
G0124	Screen c/v thin layer by MD							
G0141	"Scr c/v cyto,autosys and md"							
G0143	"Scr c/v cyto,thinlayer,rescr"							
G0144	"Scr c/v cyto,thinlayer,rescr"							
G0145 	"Scr c/v cyto,thinlayer,rescr"							
G0147	"Scr c/v cyto, automated sys"							
G0148	"Scr c/v cyto, autosys, rescr"							
G0306	CBC/diffwbc w/o platelet							
G0307	CBC without platelet							
G0328	Fecal blood scrn immunoassay							
P2028	Cephalin floculation test							
P2029	Congo red blood test							
P2033	Blood thymol turbidity 							
P2038	Blood mucoprotein							
P3000	Screen pap by tech w md supv							
P3001	Screening pap smear by phys							
P9612	Catheterize for urine spec							
P9615	Urine specimen collect mult 							
Q0111	Wet mounts/ w preparations							
Q0112	Potassium hydroxide preps							
Q0113	Pinworm examinations							
Q0114	Fern test							
Q0115	Post-coital mucous exam							
								
"PHYSICAL THERAPY, OCCUPATIONAL THERAPY, AND SPEECH-LANGUAGE PATHOLOGY"								
								
INCLUDE the following CPT codes for physical therapy/occupational therapy/speech-language pathology services in the 97000 series:								
								
97001	Pt evaluation							
97002	Pt re-evaluation							
97003	Ot evaluation							
97004	Ot re-evaluation							
97010	Hot or cold packs therapy							
97012	Mechanical traction therapy							
97016	Vasopneumatic device therapy							
97018	Paraffin bath therapy							
97020	Microwave therapy							
97022	Whirlpool therapy							
97024	"Diathermy eg, microwave"							
97026	Infrared therapy							
97028	Ultraviolet therapy							
97032	Electrical stimulation							
97033	Electric current therapy							
97034	Contrast bath therapy							
97035	Ultrasound therapy							
97036	Hydrotherapy							
97039	Physical therapy treatment							
97110	Therapeutic exercises							
97112	Neuromuscular reeducation							
97113	Aquatic therapy/exercises							
97116	Gait training therapy							
97124	Massage therapy							
97139	Physical medicine procedure							
97140	Manual therapy							
97150	Group therapeutic procedures							
97504	Orthotic training							
97520	Prosthetic training							
97530	Therapeutic activities							
97532	Cognitive skills development							
97533	Sensory integration							
97535	Self care mngment training							
97537	Community/work reintegration							
97542	Wheelchair mngment training							
97545	Work hardening							
97546	Work hardening add-on							
97597	Active wound care/20cm or <							
97598	Active wound care > 20cm							
97602	Wound(s) care nonselective							
97605	"Neg press wound tx, < 50 cm"							
97606	"Neg press wound tx, > 50 cm"							
97703	Prosthetic checkout							
97750	Physical performance test							
97755	Assistive technology assess							
97799	Physical medicine procedure							
								
INCLUDE the following CPT codes for physical therapy/occupational therapy/speech-language pathology services not in the 97000 series:								
								
64550	Apply neurostimulator							
90901	"Biofeedback train, any meth"							
90911	Biofeedback peri/uro/rectal							
92507	Speech/hearing therapy							
92508	Speech/hearing therapy							
92526	Oral function therapy							
92597	Oral speech device eval							
92607	"Ex for speech device rx, 1hr"							
92608	Ex for speech device rx addl							
92609	Use of speech device service							
92610	Evaluate swallowing function							
92611	Motion fluoroscopy/swallow							
92612	Endoscopy swallow tst (fees)							
92614	Laryngoscopic sensory test							
92616	Fees w/laryngeal sense test							
93797	Cardiac rehab							
93798	Cardiac rehab/monitor							
94667	Chest wall manipulation							
94668	Chest wall manipulation 							
95831	"Limb muscle testing, manual"							
95832	"Hand muscle testing, manual"							
95833	"Body muscle testing, manual"							
95834	"Body muscle testing, manual"							
95851	Range of motion measurements							
95852	Range of motion measurements							
96000	"Motion analysis, video/3d"							
96001	Motion test w/ft press meas							
96002	Dynamic surface emg							
96003	Dynamic fine wire emg							
96105	Assessment of aphasia 							
96110	"Developmental test, lim"							
96111	"Developmental test, extend"							
96115	Neurobehavior status exam							
0029T	Magnetic tx for incontinence							
								
INCLUDE the following HCPCS Level II codes for physical therapy/occupational therapy/speech-language pathology services:								
								
G0279	"Extracorp shock tx, elbow epi"							
G0280	Extracorp shock tx other than							
G0281	Elec stim unattend for press							
G0283	Elec stim other than wound							
G0329	Electromagntic tx for ulcers							
								
RADIOLOGY AND CERTAIN OTHER IMAGING SERVICES								
								
INCLUDE the following codes in the CPT 70000 series:								
								
70100	X-ray exam of jaw							
70110	X-ray exam of jaw							
70120	X-ray exam of mastoids							
70130	X-ray exam of mastoids							
70134	X-ray exam of middle ear							
70140	X-ray exam of facial bones							
70150	X-ray exam of facial bones							
70160	X-ray exam of nasal bones							
70190	X-ray exam of eye sockets							
70200	X-ray exam of eye sockets							
70210	X-ray exam of sinuses							
70220	X-ray exam of sinuses							
70240	"X-ray exam, pituitary saddle"							
70250	X-ray exam of skull							
70260	X-ray exam of skull							
70300	X-ray exam of teeth							
70310	X-ray exam of teeth							
70320	Full mouth x-ray of teeth							
70328	X-ray exam of jaw joint							
70330	X-ray exam of jaw joints							
70336	"Magnetic image, jaw joint"							
70350	X-ray head for orthodontia							
70355	Panoramic x-ray of jaws							
70360	X-ray exam of neck							
70370	Throat x-ray & fluoroscopy							
70371	"Speech evaluation, complex"							
70380	X-ray exam of salivary gland							
70450	Ct head/brain w/o dye							
70460	Ct head/brain w/dye							
70470	Ct head/brain w/o & w/dye							
70480	Ct orbit/ear/fossa w/o dye							
70481	Ct orbit/ear/fossa w/dye 							
70482	Ct orbit/ear/fossa w/o&w/dye							
70486	Ct maxillofacial w/o dye							
70487	Ct maxillofacial w/dye							
70488	Ct maxillofacial w/o & w/dye							
70490	Ct soft tissue neck w/o dye							
70491	Ct soft tissue neck w/dye							
70492	Ct sft tsue nck w/o & w/dye							
70496	"Ct angiography, head"							
70498	"Ct angiography, neck"							
70540	Mri orbit/face/neck w/o dye							
70542	Mri orbit/face/neck w/dye							
70543	Mri orbt/fac/nck w/o & w/dye							
70544	Mr angiography head w/o dye							
70545	Mr angiography head w/dye							
70546	Mr angiograph head w/o&w/dye							
70547	Mr angiography neck w/o dye							
70548	Mr angiography neck w/dye							
70549	Mr angiograph neck w/o&w/dye							
70551	Mri brain w/o dye							
70552	Mri brain w/dye							
70553	Mri brain w/o & w/dye 							
71010	Chest x-ray							
71015	Chest x-ray							
71020	Chest x-ray							
71021	Chest x-ray							
71022	Chest x-ray							
71023	Chest x-ray and fluoroscopy							
71030	Chest x-ray							
71034	Chest x-ray and fluoroscopy							
71035	Chest x-ray							
71100	X-ray exam of ribs							
71101	X-ray exam of ribs/chest							
71110	X-ray exam of ribs							
71111	X-ray exam of ribs/chest							
71120	X-ray exam of breastbone							
71130	X-ray exam of breastbone							
71250	Ct thorax w/o dye							
71260	Ct thorax w/dye							
71270	Ct thorax w/o & w/dye							
71275	"Ct angiography, chest"							
71550	Mri chest w/o dye							
71551	Mri chest w/dye							
71552	Mri chest w/o & w/dye							
71555	Mri angio chest w or w/o dye							
72010	X-ray exam of spine							
72020	X-ray exam of spine							
72040	X-ray exam of neck spine							
72050	X-ray exam of neck spine							
72052	X-ray exam of neck spine							
72069	X-ray exam of trunk spine							
72070	X-ray exam of thoracic spine							
72072	X-ray exam of thoracic spine							
72074	X-ray exam of thoracic spine							
72080	X-ray exam of trunk spine							
72090	X-ray exam of trunk spine							
72100	X-ray exam of lower spine							
72110	X-ray exam of lower spine							
72114	X-ray exam of lower spine							
72120	X-ray exam of lower spine							
72125	Ct neck spine w/o dye							
72126	Ct neck spine w/dye							
72127	Ct neck spine w/o & w/dye							
72128	Ct chest spine w/o dye							
72129	Ct chest spine w/dye							
72130	Ct chest spine w/o & w/dye							
72131	Ct lumbar spine w/o dye							
72132	Ct lumbar spine w/dye							
72133	Ct lumbar spine w/o & w/dye							
72141	Mri neck spine w/o dye							
72142	Mri neck spine w/dye							
72146	Mri chest spine w/o dye							
72147	Mri chest spine w/dye							
72148	Mri lumbar spine w/o dye							
72149	Mri lumbar spine w/dye							
72156	Mri neck spine w/o & w/dye							
72157	Mri chest spine w/o & w/dye							
72158	Mri lumbar spine w/o & w/dye							
72170	X-ray exam of pelvis							
72190	X-ray exam of pelvis							
72191	Ct angiograph pelv w/o&w/dye							
72192	Ct pelvis w/o dye							
72193	Ct pelvis w/dye							
72194	Ct pelvis w/o & w/dye							
72195	Mri pelvis w/o dye							
72196	Mri pelvis w/dye							
72197	Mri pelvis w/o & w/dye							
72198	Mr angio pelvis w/o & w/dye							
72200	X-ray exam sacroiliac joints							
72202	X-ray exam sacroiliac joints							
72220	X-ray exam of tailbone							
73000	X-ray exam of collar bone							
73010	X-ray exam of shoulder blade							
73020	X-ray exam of shoulder							
73030	X-ray exam of shoulder							
73050	X-ray exam of shoulders							
73060	X-ray exam of humerus							
73070	X-ray exam of elbow							
73080	X-ray exam of elbow							
73090	X-ray exam of forearm							
73092	"X-ray exam of arm, infant"							
73100	X-ray exam of wrist							
73110	X-ray exam of wrist							
73120	X-ray exam of hand							
73130	X-ray exam of hand							
73140	X-ray exam of finger(s)							
73200	Ct upper extremity w/o dye							
73201	Ct upper extremity w/dye							
73202	Ct uppr extremity w/o&w/dye							
73206	Ct angio upr extrm w/o&w/dye							
73218	Mri upper extremity w/o dye							
73219	Mri upper extremity w/dye							
73220	Mri uppr extremity w/o&w/dye							
73221	Mri joint upr extrem w/o dye							
73222	Mri joint upr extrem w/dye							
73223	Mri joint upr extr w/o&w/dye							
73500	X-ray exam of hip							
73510	X-ray exam of hip							
73520	X-ray exam of hips							
73540	X-ray exam of pelvis & hips							
73550	X-ray exam of thigh							
73560	"X-ray exam of knee, 1 or 2"							
73562	"X-ray exam of knee, 3"							
73564	"X-ray exam, knee, 4 or more"							
73565	X-ray exam of knees							
73590	X-ray exam of lower leg							
73592	"X-ray exam of leg, infant"							
73600	X-ray exam of ankle							
73610	X-ray exam of ankle							
73620	X-ray exam of foot							
73630	X-ray exam of foot							
73650	X-ray exam of heel							
73660	X-ray exam of toe(s)							
73700	Ct lower extremity w/o dye							
73701	Ct lower extremity w/dye							
73702	Ct lwr extremity w/o&w/dye							
73706	Ct angio lwr extr w/o&w/dye							
73718	Mri lower extremity w/o dye							
73719	Mri lower extremity w/dye							
73720	Mri lwr extremity w/o&w/dye							
73721	Mri jnt of lwr extre w/o dye							
73722	Mri joint of lwr extr w/dye							
73723	Mri joint lwr extr w/o&w/dye							
73725	Mr ang lwr ext w or w/o dye							
74000	X-ray exam of abdomen							
74010	X-ray exam of abdomen							
74020	X-ray exam of abdomen							
74022	"X-ray exam series, abdomen"							
74150	Ct abdomen w/o dye							
74160	Ct abdomen w/dye							
74170	Ct abdomen w/o & w/dye							
74175	Ct angio abdom w/o & w/dye							
74181	Mri abdomen w/o dye							
74182	Mri abdomen w/dye							
74183	Mri abdomen w/o & w/dye							
74185	"Mri angio, abdom w orw/o dye"							
74210	Contrst x-ray exam of throat							
74220	"Contrast x-ray, esophagus"							
74230	"Cine/vid x-ray, throat/esoph"							
74240	"X-ray exam, upper gi tract"							
74241	"X-ray exam, upper gi tract"							
74245	"X-ray exam, upper gi tract"							
74246	Contrst x-ray uppr gi tract							
74247	Contrst x-ray uppr gi tract							
74249	Contrst x-ray uppr gi tract							
74250	X-ray exam of small bowel							
74290	"Contrast x-ray, gallbladder"							
74291	"Contrast x-rays, gallbladder"							
74710	X-ray measurement of pelvis							
75552	Heart mri for morph w/o dye							
75553	Heart mri for morph w/dye							
75554	Cardiac MRI/function							
75555	Cardiac MRI/limited study							
75635	Ct angio abdominal arteries							
76000	Fluoroscope examination							
76006	X-ray stress view							
76010	"X-ray, nose to rectum"							
76020	X-rays for bone age							
76040	"X-rays, bone evaluation"							
76061	"X-rays, bone survey"							
76062	"X-rays, bone survey"							
76065	"X-rays, bone evaluation"							
76066	"Joint survey, single view"							
76070	"Ct bone density, axial"							
76071	"Ct bone density, peripheral"							
76075	"Dxa bone density, axial"							
76076	Dxa bone density/peripheral							
76077	Dxa bone density/v-fracture							
76078	Radiographic absorptiometry							
76082	Computer mammogram add-on							
76083	Computer mammogram add-on							
76090	"Mammogram, one breast"							
76091	"Mammogram, both breasts"							
76092	"Mammogram, screening"							
76093	"Magnetic image, breast"							
76094	"Magnetic image, both breasts"							
76100	X-ray exam of body section							
76101	Complex body section x-ray							
76102	Complex body section x-rays							
76120	Cine/video x-rays							
76125	Cine/video x-rays add-on							
76150	"X-ray exam, dry process"							
76370	Ct scan for therapy guide							
76375	3d/holograph reconstr add-on							
76380	CAT scan follow-up study							
76400	"Magnetic image, bone marrow"							
76499	Radiographic procedure							
76506	Echo exam of head							
76510	"Ophth us, b & quant a"							
76511	"Ophth us, quant a only"							
76512	"Ophth us, b w/non-quant a"							
76513	"Echo exam of eye, water bath"							
76514	"Echo exam of eye, thickness"							
76516	Echo exam of eye							
76519	Echo exam of eye							
76536	Us exam of head and neck							
76604	"Us exam, chest, b-scan"							
76645	"Us exam, breast(s)"							
76700	"Us exam, abdom, complete"							
76705	Echo exam of abdomen							
76770	"Us exam abdo back wall, comp"							
76775	"Us exam abdo back wall, lim"							
76778	Us exam kidney transplant							
76800	"Us exam, spinal canal"							
76801	"Ob us < 14 wks, single fetus"							
76802	"Ob us < 14 wks, addl fetus"							
76805	"Ob us >/= 14 wks, sngl fetus"							
76810	"Ob us >/= 14 wks, addl fetus"							
76811	"Ob us, detailed, sngl fetus"							
76812	"Ob us, detailed, addl fetus"							
76815	"Ob us, limited, fetus(s)"							
76816	"Ob us, follow-up, per fetus"							
76818	Fetal biophys profile w/nst							
76819	Fetal biophys profil w/o nst							
76820	Umbilical artery echo							
76821	Middle cerebral artery echo							
76825	Echo exam of fetal heart							
76826	Echo exam of fetal heart							
76827	Echo exam of fetal heart							
76828	Echo exam of fetal heart							
76856	"Us exam, pelvic, complete"							
76857	"Us exam, pelvic, limited"							
76870	"Us exam, scrotum"							
76880	"Us exam, extremity"							
76885	"Us exam infant hips, dynamic"							
76886	"Us exam infant hips, static"							
76970	Ultrasound exam follow-up							
76977	Us bone density measure							
76999	Echo examination procedure							
								
INCLUDE the following CPT codes for echocardiology and vascular ultrasound:								
								
93303	Echo transthoracic							
93304	Echo transthoracic							
93307	Echo exam of heart							
93308	Echo exam of heart							
93320	"Doppler echo exam, heart [if used in conjunction with 93303-93308]"							
93321	"Doppler echo exam, heart [if used in conjunction with 93303-93308]"							
93325	Doppler color flow add-on [if used in conjunction with 93303-93308]							
93875	Extracranial study							
93880	Extracranial study							
93882	Extracranial study							
93886	Intracranial study							
93888	Intracranial study							
93890	"Tcd, vasoreactivity study"							
93892	"Tcd, emboli detect w/o inj"							
93922	Extremity study							
93923	Extremity study							
93924	Extremity study							
93925	Lower extremity study							
93926	Lower extremity study							
93930	Upper extremity study							
93931	Upper extremity study							
93965	Extremity study							
93970	Extremity study							
93971	Extremity study							
93975	Vascular study							
93976	Vascular study							
93978	Vascular study							
93979	Vascular study							
93980	Penile vascular study							
93981	Penile vascular study							
93990	Doppler flow testing							
								
INCLUDE the following CPT and HCPCS Level II codes:								
								
51798	Us urine capacity measure							
78350	"Bone mineral, single photon"							
91110	Gi tract capsule endoscopy							
0028T	Dexa body composition study							
0042T	"Ct perfusion w/contrast, cbf"							
0067T	Ct colonography;dx							
G0130	Single energy x-ray study							
G0202	Screeningmammographydigital							
G0204	Diagnosticmammographydigital							
G0206	Diagnosticmammographydigital							
G0288	"Recon, CTA for surg plan"							
Q0092	Set up port xray equipment 							
R0070	Transport portable x-ray							
R0075	Transport port x-ray multipl							
								
RADIATION THERAPY SERVICES AND SUPPLIES								
								
INCLUDE the following codes in the CPT 70000 series:								
								
77261	Radiation therapy planning							
77262	Radiation therapy planning							
77263	Radiation therapy planning							
77280	Set radiation therapy field							
77285	Set radiation therapy field							
77290	Set radiation therapy field							
77295	Set radiation therapy field							
77299	Radiation therapy planning							
77300	Radiation therapy dose plan							
77301	"Radiotherapy dose plan, imrt"							
77305	Teletx isodose plan simple							
77310	Teletx isodose plan intermed							
77315	Teletx isodose plan complex							
77321	Special teletx port plan							
77326	Brachytx isodose calc simp							
77327	Brachytx isodose calc interm							
77328	Brachytx isodose plan compl							
77331	Special radiation dosimetry							
77332	Radiation treatment aid(s)							
77333	Radiation treatment aid(s)							
77334	Radiation treatment aid(s)							
77336	Radiation physics consult							
77370	Radiation physics consult							
77399	External radiation dosimetry							
77401	Radiation treatment delivery							
77402	Radiation treatment delivery							
77403	Radiation treatment delivery							
77404	Radiation treatment delivery							
77406	Radiation treatment delivery							
77407	Radiation treatment delivery							
77408	Radiation treatment delivery							
77409	Radiation treatment delivery							
77411	Radiation treatment delivery							
77412	Radiation treatment delivery							
77413	Radiation treatment delivery							
77414	Radiation treatment delivery							
77416	Radiation treatment delivery							
77417	Radiology port film(s)							
77418	"Radiation tx delivery, imrt"							
77427	"Radiation tx management, x5"							
77431	Radiation therapy management							
77432	Stereotactic radiation trmt							
77470	Special radiation treatment							
77499	Radiation therapy management							
77520	"Proton trmt, simple w/o comp"							
77522	"Proton trmt, simple w/comp"							
77523	"Proton trmt, intermediate"							
77525	"Proton treatment, complex"							
77600	Hyperthermia treatment							
77605	Hyperthermia treatment							
77610	Hyperthermia treatment							
77615	Hyperthermia treatment							
77620	Hyperthermia treatment							
77750	Infuse radioactive materials							
77761	Apply intrcav radiat simple							
77762	Apply intrcav radiat interm							
77763	Apply intrcav radiat compl							
77776	Apply interstit radiat simpl							
77777	Apply interstit radiat inter							
77778	Apply interstit radiat compl							
77781	High intensity brachytherapy							
77782	High intensity brachytherapy							
77783	High intensity brachytherapy							
77784	High intensity brachytherapy							
77789	Apply surface radiation							
77790	Radiation handling							
77799	Radium/radioisotope therapy							
								
INCLUDE the following CPT and HCPCS Level II codes classified elsewhere:								
								
19296	Place po breast cath for rad							
19297	Place breast cath for rad							
19298	Place breast rad tube/caths							
31643	Diag bronchoscope/catheter							
55859	"Percut/needle insert, pros"							
57155	Insert uteri tandems/ovoids							
58346	Insert heyman uteri capsule							
61770	Incise skull for treatment							
61793	Focus radiation beam							
92974	"Cath place, cardio brachytx"							
0073T	"Delivery, comp imrt"							
0082T	Stereotactic rad delivery							
0083T	Stereotactic rad tx mngmt							
G0173	"Stereo radiosurgery, complete"							
G0242	Multisource photon ster plan							
G0243	Multisour photon stero treat							
G0251	Linear acc based stero radio							
G0338	Linear accelerator stero pln							
G0339	"Robot lin-radsurg com, first"							
G0340	Robt lin-radsurg fractx 2-5							
								
EPO AND OTHER DIALYSIS-RELATED DRUGS								
								
The physician self-referral prohibition does not apply to the following codes for EPO and other dialysis-related drugs furnished in or by an ESRD facility if the conditions in 411.355(g) are satisfied:								
								
J0630	Calcitonin salmon injection							
J0636	Inj calcitriol per 0.1 mcg							
J0895	Deferoxamine mesylate inj							
J1270	"Injection, doxercalciferol"							
J1750	Iron dextran							
J1756	Iron sucrose injection							
J1955	Inj levocarnitine per 1 gm							
J2501	Paricalcitol							
J2916	Na ferric gluconate complex							
J2993 	Reteplase injection							
J2995	Inj streptokinase /250000 IU							
J2997	Alteplase recombinant							
J3364	Urokinase 5000 IU injection							
P9041	"Albumin (human),5%, 50ml"							
P9045	"Albumin (human), 5%, 250ml"							
P9046	"Albumin (human), 25%, 20ml"							
P9047	"Albumin (human), 25%, 50ml"							
Q4054	"Darbopoetin alfa, esrd use"							
Q4055	"Epoetin alfa, esrd use"							
								
"PREVENTIVE SCREENING TESTS, IMMUNIZATIONS AND VACCINES"								
								
The physician self-referral prohibition does not apply to the following tests if they are performed for screening purposes and satisfy the conditions in 411.355(h):								
								
76083	Computer mammogram add-on							
76092	"Mammogram, screening"							
80061	"Lipid panel [only when billed with one of the following ICD-9-CM codes:  V81.0, V81.1, or V.81.2] "							
82465	"Assay, bld/serum cholesterol [only when billed with one of the following ICD-9-CM codes:  V81.0, V81.1, or V.81.2] "							
82947	"Assay, glucose, blood quant [only when billed with ICD-9-CM code V77.1]"							
82950	Glucose test [only when billed with ICD-9-CM code V77.1]							
82951	Glucose tolerance test (GTT) [only when billed with ICD-9-CM code V77.1]							
83718	"Assay of lipoprotein [only when billed with one of the following ICD-9-CM codes:  V81.0, V81.1, or V.81.2] "							
84478	"Assay of triglycerides [only when billed with one of the following ICD-9-CM codes:  V81.0, V81.1, or V.81.2] "							
G0103	"Psa, total screening"							
G0107	CA screen; fecal blood test							
G0123	Screen cerv/vag thin layer							
G0124	Screen c/v thin layer by MD							
G0141	"Scr c/v cyto,autosys and md"							
G0143	"Scr c/v cyto,thinlayer,rescr"							
G0144	"Scr c/v cyto,thinlayer,rescr"							
G0145 	"Scr c/v cyto,thinlayer,rescr"							
G0147	"Scr c/v cyto, automated sys"							
G0148	"Scr c/v cyto, autosys, rescr"							
G0202	Screening mammographydigital							
G0328	Fecal blood scrn immunoassay							
P3000	Screen pap by tech w md supv							
P3001	Screening pap smear by phys							
								
The physician self-referral prohibition does not apply to the following immunization and vaccine codes if they satisfy the conditions in 411.355(h):								
								
90655	Flu vaccine no preserv 6-35m							
90656	Flu vaccine no preserv 3 & >							
90657	"Flu vaccine, 6-35 mo, im"							
90658	"Flu vaccine, age 3 & >, im"							
90732	Pneumococcal vaccine							
90740	"Hepb vacc, ill pat 3 dose im"							
90743	"Hep b vacc, adol, 2 dose, im"							
90744	Hepb vacc ped/adol 3 dose im							
90746	"Hep b vaccine, adult, im"							
90747	"Hepb vacc, ill pat 4 dose im"							
								
1  CPT codes and descriptions only are copyright 2004 American Medical Association.  All rights are reserved and applicable FARS/DFARS clauses apply.								
								
"2  This list does not include codes for the following designated health service (DHS) categories: durable medical equipment and supplies; parenteral and enteral nutrients, equipment and supplies; prosthetics, orthotics, and prosthetic devices and supplies; home health services; outpatient prescription drugs; and inpatient and outpatient hospital services.  For the definitions of these DHS categories, refer to 42 CFR 411.351.  For more information, refer to https://www.cms.gov/PhysicianSelfReferral/40_List_of_Codes.asp#TopOfPage. "								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
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