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LCD Reference Article Billing and Coding Article

Billing and Coding: Category III Codes

A56902

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A56902
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Category III Codes
Article Type
Billing and Coding
Original Effective Date
08/29/2019
Revision Effective Date
03/28/2024
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

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CMS National Coverage Policy

N/A

Article Guidance

Article Text

The billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated LCD L35490 Category III Codes with the exception of the following CPT codes:

  • 2021 CPT/HCPCS Annual code update: 0295T, 0296T, 0297T, and 0298T deleted. Effective 01/01/2021. Please refer to LCD L34636 Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring) and A57476 Billing and Coding: Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring). The physician (MD/DO) performing the service must meet all criteria in this LCD and Billing and Coding Article.

  • CPT Codes 0446T- Creation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system activation and patient training, 0447T- Removal of implantable interstitial glucose sensor from subcutaneous pocket via incision, and 0448T- Removal of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic site and insertion of new implantable sensor, including system activation. Please refer to L38686 Implantable Continuous Glucose Monitors (I-CGM) and A58213 Billing and Coding: Implantable Continuous Glucose Monitors (I-CGM). The physician (MD/DO) performing the service must meet all criteria in this LCD and Billing and Coding Article. Effective 10/11/2020.

  • CPT Code 0421T – Transurethral waterjet ablation of prostate, including control of post-operative bleeding, including ultrasound guidance, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed) AND HCPCS Code C2596 – Probe, image guided, robotic, waterjet ablation. Please refer to L38682 Transurethral Waterjet Ablation of the Prostate and A58209 Billing and Coding: Transurethral Waterjet Ablation of the Prostate. The provider performing this service must meet all criteria in that LCD and Billing and Coding Article. Effective 12/27/2020.

  • CPT Codes 0501T-0504T: coverage in L35490 no longer applicable. Please refer to L38839 Non-Invasive Fractional Flow Reserve (FFR) for Stable Ischemic Heart Disease and A58473 Billing and Coding: Non-Invasive Fractional Flow Reserve (FFR) for Stable Ischemic Heart Disease for Coverage Indications, Limitations, and/or Medical Necessity. Effective 04/25/2021.

Frequency Limitation

Medicare may cover only 1 unit per eye, per date of service of CPT code 0449T for insertion of glaucoma drainage device(s) into the subconjunctival space (e.g., XEN45®), when the medically reasonable and necessary criteria as stated in the LCD are met.

Documentation Requirements

  1. All documentation must be maintained in the patient's medical record and must support the medical necessity of the services as directed in this article and be made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

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Group 1

(12 Codes)
Group 1 Paragraph

The following lists Category III services determined by WPS GHA to be reasonable and medically necessary. Coverage will only be allowed when the service is delivered in clinical situations meeting medical necessity. For services addressed in a separate LCD and associated Billing and Coding Article, all criteria addressed in that LCD and associated Billing and Coding Article must be met.

 Group 1 Codes
Code Description
0042T CEREBRAL PERFUSION ANALYSIS USING COMPUTED TOMOGRAPHY WITH CONTRAST ADMINISTRATION, INCLUDING POST-PROCESSING OF PARAMETRIC MAPS WITH DETERMINATION OF CEREBRAL BLOOD FLOW, CEREBRAL BLOOD VOLUME, AND MEAN TRANSIT TIME
0075T TRANSCATHETER PLACEMENT OF EXTRACRANIAL VERTEBRAL ARTERY STENT(S), INCLUDING RADIOLOGIC SUPERVISION AND INTERPRETATION, OPEN OR PERCUTANEOUS; INITIAL VESSEL
0076T TRANSCATHETER PLACEMENT OF EXTRACRANIAL VERTEBRAL ARTERY STENT(S), INCLUDING RADIOLOGIC SUPERVISION AND INTERPRETATION, OPEN OR PERCUTANEOUS; EACH ADDITIONAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
0184T EXCISION OF RECTAL TUMOR, TRANSANAL ENDOSCOPIC MICROSURGICAL APPROACH (IE, TEMS), INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)
0253T INSERTION OF ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, INTO THE SUPRACHOROIDAL SPACE
0308T INSERTION OF OCULAR TELESCOPE PROSTHESIS INCLUDING REMOVAL OF CRYSTALLINE LENS OR INTRAOCULAR LENS PROSTHESIS
0394T HIGH DOSE RATE ELECTRONIC BRACHYTHERAPY, SKIN SURFACE APPLICATION, PER FRACTION, INCLUDES BASIC DOSIMETRY, WHEN PERFORMED
0395T HIGH DOSE RATE ELECTRONIC BRACHYTHERAPY, INTERSTITIAL OR INTRACAVITARY TREATMENT, PER FRACTION, INCLUDES BASIC DOSIMETRY, WHEN PERFORMED
0398T MAGNETIC RESONANCE IMAGE GUIDED HIGH INTENSITY FOCUSED ULTRASOUND (MRGFUS), STEREOTACTIC ABLATION LESION, INTRACRANIAL FOR MOVEMENT DISORDER INCLUDING STEREOTACTIC NAVIGATION AND FRAME PLACEMENT WHEN PERFORMED
0449T INSERTION OF AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, INTO THE SUBCONJUNCTIVAL SPACE; INITIAL DEVICE
0450T INSERTION OF AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, INTO THE SUBCONJUNCTIVAL SPACE; EACH ADDITIONAL DEVICE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
0474T INSERTION OF ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITH CREATION OF INTRAOCULAR RESERVOIR, INTERNAL APPROACH, INTO THE SUPRACILIARY SPACE

Group 2

(1 Code)
Group 2 Paragraph

0042T

 Group 2 Codes
Code Description
0042T CEREBRAL PERFUSION ANALYSIS USING COMPUTED TOMOGRAPHY WITH CONTRAST ADMINISTRATION, INCLUDING POST-PROCESSING OF PARAMETRIC MAPS WITH DETERMINATION OF CEREBRAL BLOOD FLOW, CEREBRAL BLOOD VOLUME, AND MEAN TRANSIT TIME

Group 3

(2 Codes)
Group 3 Paragraph

0075T and 0076T
Please refer to the CPT Professional code book: use 0076T in conjunction with 0075T.

 Group 3 Codes
Code Description
0075T TRANSCATHETER PLACEMENT OF EXTRACRANIAL VERTEBRAL ARTERY STENT(S), INCLUDING RADIOLOGIC SUPERVISION AND INTERPRETATION, OPEN OR PERCUTANEOUS; INITIAL VESSEL
0076T TRANSCATHETER PLACEMENT OF EXTRACRANIAL VERTEBRAL ARTERY STENT(S), INCLUDING RADIOLOGIC SUPERVISION AND INTERPRETATION, OPEN OR PERCUTANEOUS; EACH ADDITIONAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Group 4

(2 Codes)
Group 4 Paragraph

0253T and 0474T

 Group 4 Codes
Code Description
0253T INSERTION OF ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, INTO THE SUPRACHOROIDAL SPACE
0474T INSERTION OF ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITH CREATION OF INTRAOCULAR RESERVOIR, INTERNAL APPROACH, INTO THE SUPRACILIARY SPACE

Group 5

(1 Code)
Group 5 Paragraph

0308T
Claims submitted by Part A providers and ambulatory surgical centers for device pass-through category C1840 must be billed with HCPCS code 0308T (insertion of ocular telescope prosthesis including removal of crystalline lens) to receive pass-through payment. Effective July 1, 2012.

 Group 5 Codes
Code Description
0308T INSERTION OF OCULAR TELESCOPE PROSTHESIS INCLUDING REMOVAL OF CRYSTALLINE LENS OR INTRAOCULAR LENS PROSTHESIS

Group 6

(1 Code)
Group 6 Paragraph

0398T

 Group 6 Codes
Code Description
0398T MAGNETIC RESONANCE IMAGE GUIDED HIGH INTENSITY FOCUSED ULTRASOUND (MRGFUS), STEREOTACTIC ABLATION LESION, INTRACRANIAL FOR MOVEMENT DISORDER INCLUDING STEREOTACTIC NAVIGATION AND FRAME PLACEMENT WHEN PERFORMED

Group 7

(2 Codes)
Group 7 Paragraph

0449T, 0450T

 Group 7 Codes
Code Description
0449T INSERTION OF AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, INTO THE SUBCONJUNCTIVAL SPACE; INITIAL DEVICE
0450T INSERTION OF AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, INTO THE SUBCONJUNCTIVAL SPACE; EACH ADDITIONAL DEVICE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Group 8

(8 Codes)
Group 8 Paragraph

The following CPT/HCPCS codes are non-covered

 Group 8 Codes
Code Description
0525T INSERTION OR REPLACEMENT OF INTRACARDIAC ISCHEMIA MONITORING SYSTEM, INCLUDING TESTING OF THE LEAD AND MONITOR, INITIAL SYSTEM PROGRAMMING, AND IMAGING SUPERVISION AND INTERPRETATION; COMPLETE SYSTEM (ELECTRODE AND IMPLANTABLE MONITOR)
0526T INSERTION OR REPLACEMENT OF INTRACARDIAC ISCHEMIA MONITORING SYSTEM, INCLUDING TESTING OF THE LEAD AND MONITOR, INITIAL SYSTEM PROGRAMMING, AND IMAGING SUPERVISION AND INTERPRETATION; ELECTRODE ONLY
0527T INSERTION OR REPLACEMENT OF INTRACARDIAC ISCHEMIA MONITORING SYSTEM, INCLUDING TESTING OF THE LEAD AND MONITOR, INITIAL SYSTEM PROGRAMMING, AND IMAGING SUPERVISION AND INTERPRETATION; IMPLANTABLE MONITOR ONLY
0528T PROGRAMMING DEVICE EVALUATION (IN PERSON) OF INTRACARDIAC ISCHEMIA MONITORING SYSTEM WITH ITERATIVE ADJUSTMENT OF PROGRAMMED VALUES, WITH ANALYSIS, REVIEW, AND REPORT
0529T INTERROGATION DEVICE EVALUATION (IN PERSON) OF INTRACARDIAC ISCHEMIA MONITORING SYSTEM WITH ANALYSIS, REVIEW, AND REPORT
0530T REMOVAL OF INTRACARDIAC ISCHEMIA MONITORING SYSTEM, INCLUDING ALL IMAGING SUPERVISION AND INTERPRETATION; COMPLETE SYSTEM (ELECTRODE AND IMPLANTABLE MONITOR)
0531T REMOVAL OF INTRACARDIAC ISCHEMIA MONITORING SYSTEM, INCLUDING ALL IMAGING SUPERVISION AND INTERPRETATION; ELECTRODE ONLY
0532T REMOVAL OF INTRACARDIAC ISCHEMIA MONITORING SYSTEM, INCLUDING ALL IMAGING SUPERVISION AND INTERPRETATION; IMPLANTABLE MONITOR ONLY
N/A

CPT/HCPCS Modifiers

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Group 1

Group 1 Paragraph

N/A

 Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

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Group 1

(10 Codes)
Group 1 Paragraph

0042T

 Group 1 Codes
Code Description
I63.031 Cerebral infarction due to thrombosis of right carotid artery
I63.032 Cerebral infarction due to thrombosis of left carotid artery
I63.131 Cerebral infarction due to embolism of right carotid artery
I63.132 Cerebral infarction due to embolism of left carotid artery
I63.311 Cerebral infarction due to thrombosis of right middle cerebral artery
I63.312 Cerebral infarction due to thrombosis of left middle cerebral artery
I63.411 Cerebral infarction due to embolism of right middle cerebral artery
I63.412 Cerebral infarction due to embolism of left middle cerebral artery
I63.511 Cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery
I63.512 Cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery

Group 2

(24 Codes)
Group 2 Paragraph

The following ICD-10 Codes apply to CPT codes 0253T and 0474T to support medical necessity.

 Group 2 Codes
Code Description
H40.1111 Primary open-angle glaucoma, right eye, mild stage
H40.1112 Primary open-angle glaucoma, right eye, moderate stage
H40.1121 Primary open-angle glaucoma, left eye, mild stage
H40.1122 Primary open-angle glaucoma, left eye, moderate stage
H40.1131 Primary open-angle glaucoma, bilateral, mild stage
H40.1132 Primary open-angle glaucoma, bilateral, moderate stage
H40.1211 Low-tension glaucoma, right eye, mild stage
H40.1212 Low-tension glaucoma, right eye, moderate stage
H40.1221 Low-tension glaucoma, left eye, mild stage
H40.1222 Low-tension glaucoma, left eye, moderate stage
H40.1231 Low-tension glaucoma, bilateral, mild stage
H40.1232 Low-tension glaucoma, bilateral, moderate stage
H40.1311 Pigmentary glaucoma, right eye, mild stage
H40.1312 Pigmentary glaucoma, right eye, moderate stage
H40.1321 Pigmentary glaucoma, left eye, mild stage
H40.1322 Pigmentary glaucoma, left eye, moderate stage
H40.1331 Pigmentary glaucoma, bilateral, mild stage
H40.1332 Pigmentary glaucoma, bilateral, moderate stage
H40.1411 Capsular glaucoma with pseudoexfoliation of lens, right eye, mild stage
H40.1412 Capsular glaucoma with pseudoexfoliation of lens, right eye, moderate stage
H40.1421 Capsular glaucoma with pseudoexfoliation of lens, left eye, mild stage
H40.1422 Capsular glaucoma with pseudoexfoliation of lens, left eye, moderate stage
H40.1431 Capsular glaucoma with pseudoexfoliation of lens, bilateral, mild stage
H40.1432 Capsular glaucoma with pseudoexfoliation of lens, bilateral, moderate stage

Group 3

(52 Codes)
Group 3 Paragraph

The following ICD-10 Codes are used to support medical necessity with CPT codes 0449T and 0450T.

 Group 3 Codes
Code Description
H40.10X1 Unspecified open-angle glaucoma, mild stage
H40.10X2 Unspecified open-angle glaucoma, moderate stage
H40.10X3 Unspecified open-angle glaucoma, severe stage
H40.10X4 Unspecified open-angle glaucoma, indeterminate stage
H40.1111 Primary open-angle glaucoma, right eye, mild stage
H40.1112 Primary open-angle glaucoma, right eye, moderate stage
H40.1113 Primary open-angle glaucoma, right eye, severe stage
H40.1114 Primary open-angle glaucoma, right eye, indeterminate stage
H40.1121 Primary open-angle glaucoma, left eye, mild stage
H40.1122 Primary open-angle glaucoma, left eye, moderate stage
H40.1123 Primary open-angle glaucoma, left eye, severe stage
H40.1124 Primary open-angle glaucoma, left eye, indeterminate stage
H40.1131 Primary open-angle glaucoma, bilateral, mild stage
H40.1132 Primary open-angle glaucoma, bilateral, moderate stage
H40.1133 Primary open-angle glaucoma, bilateral, severe stage
H40.1134 Primary open-angle glaucoma, bilateral, indeterminate stage
H40.1211 Low-tension glaucoma, right eye, mild stage
H40.1212 Low-tension glaucoma, right eye, moderate stage
H40.1213 Low-tension glaucoma, right eye, severe stage
H40.1214 Low-tension glaucoma, right eye, indeterminate stage
H40.1221 Low-tension glaucoma, left eye, mild stage
H40.1222 Low-tension glaucoma, left eye, moderate stage
H40.1223 Low-tension glaucoma, left eye, severe stage
H40.1224 Low-tension glaucoma, left eye, indeterminate stage
H40.1231 Low-tension glaucoma, bilateral, mild stage
H40.1232 Low-tension glaucoma, bilateral, moderate stage
H40.1233 Low-tension glaucoma, bilateral, severe stage
H40.1234 Low-tension glaucoma, bilateral, indeterminate stage
H40.1311 Pigmentary glaucoma, right eye, mild stage
H40.1312 Pigmentary glaucoma, right eye, moderate stage
H40.1313 Pigmentary glaucoma, right eye, severe stage
H40.1314 Pigmentary glaucoma, right eye, indeterminate stage
H40.1321 Pigmentary glaucoma, left eye, mild stage
H40.1322 Pigmentary glaucoma, left eye, moderate stage
H40.1323 Pigmentary glaucoma, left eye, severe stage
H40.1324 Pigmentary glaucoma, left eye, indeterminate stage
H40.1331 Pigmentary glaucoma, bilateral, mild stage
H40.1332 Pigmentary glaucoma, bilateral, moderate stage
H40.1333 Pigmentary glaucoma, bilateral, severe stage
H40.1334 Pigmentary glaucoma, bilateral, indeterminate stage
H40.1411 Capsular glaucoma with pseudoexfoliation of lens, right eye, mild stage
H40.1412 Capsular glaucoma with pseudoexfoliation of lens, right eye, moderate stage
H40.1413 Capsular glaucoma with pseudoexfoliation of lens, right eye, severe stage
H40.1414 Capsular glaucoma with pseudoexfoliation of lens, right eye, indeterminate stage
H40.1421 Capsular glaucoma with pseudoexfoliation of lens, left eye, mild stage
H40.1422 Capsular glaucoma with pseudoexfoliation of lens, left eye, moderate stage
H40.1423 Capsular glaucoma with pseudoexfoliation of lens, left eye, severe stage
H40.1424 Capsular glaucoma with pseudoexfoliation of lens, left eye, indeterminate stage
H40.1431 Capsular glaucoma with pseudoexfoliation of lens, bilateral, mild stage
H40.1432 Capsular glaucoma with pseudoexfoliation of lens, bilateral, moderate stage
H40.1433 Capsular glaucoma with pseudoexfoliation of lens, bilateral, severe stage
H40.1434 Capsular glaucoma with pseudoexfoliation of lens, bilateral, indeterminate stage

Group 4

(6 Codes)
Group 4 Paragraph

The following ICD-10 Code is used to support medical necessity with CPT code 0398T.

 Group 4 Codes
Code Description
G20.A1 Parkinson's disease without dyskinesia, without mention of fluctuations
G20.A2 Parkinson's disease without dyskinesia, with fluctuations
G20.B1 Parkinson's disease with dyskinesia, without mention of fluctuations
G20.B2 Parkinson's disease with dyskinesia, with fluctuations
G20.C Parkinsonism, unspecified
G25.0 Essential tremor
N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

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Group 1

(1 Code)
Group 1 Paragraph

N/A

 Group 1 Codes
Code Description
XX000 Not Applicable
N/A

ICD-10-PCS Codes

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Group 1

Group 1 Paragraph

N/A

 Group 1 Codes

N/A

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description
N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Code Description
N/A

Other Coding Information

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Group 1

Group 1 Paragraph

N/A

 Group 1 Codes

N/A

N/A

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
N/A
Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation
03/28/2024 R16

Posted 03/28/2024-Under Coding Information CPT/HCPCS Codes Group 1 Codes deleted 0275T, deleted Group 5 Paragraph and Group 5 Codes. Under ICD 10 Codes the Support Medical Necessity deleted Group 3 Paragraph and Group 3 Codes. All information for CPT code 0275T can be found in NCD 150.13. Review completed 02/21/2024.
10/01/2023 R15

Posted 09/28/2023- Under ICD-10 Codes that Support Medical Necessity Group 5 Codes deleted ICD 10 code G20 and added G20.A1, G20.A2, G20.B1, G20.B2 and G20.C. These changes are due to the 2024 ICD-10-CM Code Updates are effective 10/01/2023.
04/27/2023 R14

Posted 04/27/2023-Under Coding Information CPT/HCPCS Codes added Group 9 Paragraph-The following CPT/HCPCS codes are non-covered and added Group 9 Codes 0525T-0532T.
06/12/2022 R13

Posted 04/28/2022 - corrected Revision Effective Date from 06/11/2022 to 06/12/2022 to correspond with Effective Date of LCD L35490.
06/11/2022 R12

Posted 04/27/2022. Under Article Guidance added Frequency Limitation Medicare may cover only 1 unit per eye, per date of service of CPT code 0449T for insertion of glaucoma drainage device(s) into the subconjunctival space (e.g., XEN45®), when the medically reasonable and necessary criteria as stated in the LCD are met. Added Documentation Requirements 1)All documentation must be maintained in the patient's medical record and must support the medical necessity of the services as directed in this article and be made available to the contractor upon request, 2) Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)).The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient, and 3) The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
Under Group 4 Paragraph added H40.10X1, H40.10X2, H40.1111, H40.1112, H40.1121, H40.1122, H40.1131, H40.1132, H40.1211, H40.1212, H40.1213, H40.1214, H40.1221, H40.1222, H40.1223, H40.1224, H40.1231, H40.1232, H40.1233, H40.1234, H40.1311, H40.1312, H40.1321, H40.1322, H40.1323, H40.1331, H40.1332, H40.1411, H40.1412, H40.1421, H40.1422, H40.1431, and H40.1432 to Group 4 Codes. Under Group 5 Paragraph added G20 to Group 5 Codes.
01/01/2022 R11

12/30/2021 Annual CPT/HCPCS code updates. Under Article Guidance Article Text removed information related to deleted CPT codes 0466T and 0355T. Deleted Group 1 codes 0191T, 0376T, 0548T, 0549T, 0550T and 0551T. Under CPT/HCPCS Codes deleted Group 4 Paragraph information and deleted Group 4 Codes 0191T and 0376T. Deleted Group 9 Paragraph and Group 9 codes 0548T, 0549T, 0550T, 0551T Under ICD-10 Codes that Support Medical Necessity Group 2 Paragraph deleted CPT codes 0191T and 0376T. Deleted all of Group 6 Paragraph and Group 6 Codes.
04/25/2021 R10

03/11/2021 Added to Article Text: CPT Codes 0501T-0504T: Please refer to L38839 Non-Invasive Fractional Flow Reserve (FFR) for Stable Ischemic Heart Disease and A58473 Billing and Coding: Non-Invasive Fractional Flow Reserve (FFR) for Stable Ischemic Heart Disease for Coverage Indications, Limitations, and/or Medical Necessity. Removed CPT/HCPCS Codes/Group 1 Codes: 0501T-0504T. Removed Group 9 Paragraph/Group 9 Codes: 0501T-0504T. Removed ICD-10 Codes that Support Medical Necessity/Group 5 Paragraph: The following ICD-10 Codes are used to support medical necessity with CPT codes 0501T, 0502T, 0503T and 0504T. Removed Group 5 Codes. Reformatted numerical order. Effective 04/25/2021.
03/28/2021 R9

02/11/2021 Added to Article Text: CPT code 0355T. Please refer to L38837 Colon Capsule Endoscopy (CCE) and A58471 Billing and Coding: Colon Capsule Endoscopy (CCE). The provider performing this service must meet all criteria in that LCD and Billing and Coding Article. Effective 03/28/2021.
12/31/2020 R8

12/31/2020 2021 CPT/HCPCS Annual code update: 0295T, 0296T, 0297T, and 0298T deleted. Effective 01/01/2021. Please refer to LCD L34636 Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring) and A57476 Billing and Coding: Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring). Reformatted Article Text: CPT Code 0466T. Added to Article Text: CPT code 0421T and HCPCS code C2596. Included reference to related LCD L38682 and Article A56902 which became effective 12/27/2020.
11/26/2020 R7

11/26/2020: Updated Group 3 Paragraph: 0075T and 0076T: Please refer to the CPT Professional code book: use 0076T in conjunction with 0075T. Corrected Group 10 Paragraph: CPT code corrected from 0450T to CPT code 0550T. Included: Please refer to the CPT Professional code book: do not report 0551T in conjunction with 0548T, 0549T, 0550T.
10/29/2020 R6

10/29/2020: Please note correction for 06/25/2020 revision history: 098T should have read 0298T.
Added to article text: CPT Codes 0446T- Creation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system activation and patient training, 0447T- Removal of implantable interstitial glucose sensor from subcutaneous pocket via incision, and 0448T- Removal of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic site and insertion of new implantable sensor, including system activation. Please refer to L38686 Implantable Continuous Glucose Monitors (I-CGM) and A58213 Billing and Coding: Implantable Continuous Glucose Monitors (I-CGM). The physician (MD/DO) performing the service must meet all criteria in this LCD and Billing and Coding Article. Effective 10/11/2020. Coding Information Group 1 Paragraph: updated statement to include associated Billing and Coding Article. Removed medical necessity information and relocated to LCD L35490 to Summary of Evidence in Group 2 Paragraph 0042T; Group 7 Paragraph 0398T; and Group 9 Paragraph: 0501T, 0502T, 0503T, 0504T. Group 3 Paragraph: 0075T and 0076T. Removed reference CMS publication 100-03, Medicare National Coverage Determinations (NCD) Manual as it is located in the LCD: Utilization Guidelines. Group 4 Paragraph: removed medical description of CPT code 0191T, located in Utilization Guidelines. Group 6 Paragraph: 0308T reformatted billing guidance. Group 8 Paragraph: 0449T, 0450T removed medical description of CPT codes, located in Utilization Guidelines. Group 10 Paragraph: 0548T, 0549T, 0550T, 0551T removed medical descriptions, located in Utilization Guidelines.

Removed medical necessity information and relocated to LCD L35490 to Utilization Guidelines in Group 3 Paragraph 0075T-0076T; Group 4 Paragraph 0191T; Group 6 Paragraph 0308T; Group 8 Paragraph: 0449T, 0450T and Group 10 Paragraph: 0548T, 0549T, 0550T, 0551T.
07/01/2020 R5

06/25/2020: CPT/HCPCS Codes Group 1 Codes added: 0042T, 0275T, 0398T, 0501T, 0502T, 0503T, 0504T, 0548T, 0549T, 0550T, and 0551T. CPT/HCPCS Codes Group 1 Codes removed: 0295T, 0296T, 0297T, and 098T. The billing and coding information for these 4 CPT codes are dependent on the coverage indications, limitations and/or medical necessity described in the LCD L34636 Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring) and A57476 Billing and Coding: Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring). Updated content:
Group 2 Paragraph: 0042T; Utilization Guidelines reformatted and includes: Group 3 Paragraph: 0075T and 0076T; Group 4 Paragraph: 0191T; Group 6 Paragraph: 0308T; Group 7 Paragraph: 0398T; Group 8 Paragraph: 0449T, 0450T; Group 9 Paragraph: 0501T, 0502T, 0503T, 0504T; and Group 10 Paragraph: 0548T, 0549T, 0550T, 0551T. ICD-10 Codes that Support Medical Necessity Group 1 Paragraph: 0042T, Group 1 Codes: I63.031, I63.032, I63.131, I63.132, I63.311, I63.312, I63.411, I63.412, I63.511, and I63.512. Reformatted Group 2 Codes through Group 7 Codes for correct numerical order.
04/30/2020 R4

04/30/2020: Article text includes new format “with the exception of the following CPT codes:” Added: CPT Codes 0295T - 0298T. Please refer to A54953 Independent Diagnostic Testing Facilities – physician supervision and technician requirements. Additional guidance provided in LCD L34636 Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring) and A57476 Billing and Coding: Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring). The physician (MD/DO) performing the service must meet all criteria in this LCD and Billing and Coding Article. (Effective 04/30/2020).
CPT Codes 0466T- 0468T. Please refer to L38528 - Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea and A57944 Billing and Coding: Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea. The physician (MD/DO) performing the service must meet all criteria in this LCD and Billing and Coding Article. (Future Effective 06/14/2020) Last review completed 04/06/2020.
01/01/2020 R3

12/19/2019 CPT/HCPCS annual code update: deleted CPT 0249T from Group 1 Codes and associated L35490 effective 01/01/2020. Providers are responsible for determining the correct diagnostic and procedural coding for the services they furnish to Medicare beneficiaries.
11/01/2019 R2

Content has been moved to the new template.
10/01/2019 R1

09/26/2019: Group 4 Paragraph: removed I48.1 and I48.2 are applicable to Group 4 Paragraph. ICD-10 CM annual code updates: Group 4 added codes I48.11, I48.19, I48.20, and I48.21.
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