Medical Products and Services Requiring …...Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits

Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)

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Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the

member’s health insurance coverage. Drug preauthorization requirements are not included here.

Code Code Type Code Description Requirement

PA Ambulance or other transportation services for non-emergent reasons

PA Chiropractic Services (after 20 visits)

PA Occupational Therapy (after 30 visits)

PA Orthotics & Prosthetics with billed amount exceeding $15,000

PA Outpatient: Out-of-network services

PA Physical Therapy (after 30 visits)

PA Speech Therapy (after 30 visits)

PA Transition or Continuity of Care

PA Transplantation Services

PA 21 Place of Service

Inpatient Hospital

0-5 days length of stay, in-network: notification only

6 days or more length of stay, in-network: preauthorization

**Out of network requires preauthorization for any length of stay

PA 31 Place of Service Skil led Nursing Facility

Notification 34 Place of Service Hospice

PA 51 Place of Service

Inpatient Psychiatric Facility

0-5 days length of stay, in-network: notification only

6 days or more length of stay, in-network: preauthorization

**Out of network requires preauthorization for any length of stay

PA 55 Place of Service Residential Substance Abuse Treatment Facility

PA 56 Place of Service Psychiatric Residential Treatment Center

PA 61 Place of Service Comprehensive Inpatient Rehabilitation Facility

PA 15769 CPT Grafting of autologous soft tissue, other, harvested by direct excision

(eg, fat, dermis, fascia)

PA 15771 CPT Grafting of autologous fat harvested by liposuction technique to trunk,

breasts, scalp, arms, and/or legs; 50 cc or less injectate


2




PA 15772 CPT

Grafting of autologous fat harvested by liposuction technique to trunk,

breasts, scalp, arms, and/or legs; each additional 50 cc injectate, or

part thereof (List separately in addition to code for primary procedure)

PA 15773 CPT

Grafting of autologous fat harvested by liposuction technique to face,

eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc

or less injectate

PA 15774 CPT

Grafting of autologous fat harvested by liposuction technique to face,

eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; each

additional 25 cc injectate, or part thereof (List separately in addition to

code for primary procedure)

PA 15830 CPT Excision, excessive skin and subcutaneous tissue (includes lipectomy);

abdomen, infraumbilical panniculectomy

PA 15877 CPT Suction assisted lipectomy; trunk

PA 19318 CPT Reduction mammaplasty

PA 20932 CPT

Allograft, includes templating, cutting, placement and internal fixation,

when performed; osteoarticular, including articular surface and

contiguous bone (List separately in addition to code for primary

procedure)

PA 20933 CPT


when performed; hemicortical intercalary, partial (ie, hemicylindrical)

(List separately in addition to code for primary procedure)

PA 20934 CPT


when performed; intercalary, complete (ie, cylindrical) (List separately

in addition to code for primary procedure)

PA 20974 CPT Electrical stimulation to aid bone healing; noninvasive (nonoperative)

PA 20975 CPT Electrical stimulation to aid bone healing; invasive (operative)

PA 20979 CPT Low intensity ultrasound stimulation to aid bone healing, noninvasive

(nonoperative)

PA 22548 CPT Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2

(atlas-axis), with or without excision of odontoid process


3




PA 22551 CPT

Arthrodesis, anterior interbody, including disc space preparation,

discectomy, osteophytectomy and decompression of spinal cord

and/or nerve roots; cervical below C2

PA 22552 CPT

Arthrodesis, anterior interbody, including disc space preparation,

discectomy, osteophytectomy and decompression of spinal cord

and/or nerve roots; cervical below C2, each additional interspace (List

separately in addition to code for separate procedure)

PA 22554 CPT

Arthrodesis, anterior interbody technique, including minimal

discectomy to prepare interspace (other than for decompression);

cervical below C2

PA 22556 CPT



thoracic

PA 22558 CPT



lumbar

PA 22585 CPT



each additional interspace (List separately in addition to code for

primary procedure)

PA 22590 CPT Arthrodesis, posterior technique, craniocervical (occiput-C2)

PA 22595 CPT Arthrodesis, posterior technique, atlas-axis (C1-C2)

PA 22600 CPT Arthrodesis, posterior or posterolateral technique, single level; cervical

below C2 segment

PA 22610 CPT Arthrodesis, posterior or posterolateral technique, single level;

thoracic (with lateral transverse technique, when performed)

PA 22612 CPT Arthrodesis, posterior or posterolateral technique, single level; lumbar

(with lateral transverse technique, when performed)

PA 22614 CPT

Arthrodesis, posterior or posterolateral technique, single level; each

additional vertebral segment (List separately in addition to code for

primary procedure)


4




PA 22630 CPT

Arthrodesis, posterior interbody technique, including laminectomy

and/or discectomy to prepare interspace (other than for

decompression), single interspace; lumbar

PA 22632 CPT

Arthrodesis, posterior interbody technique, including laminectomy

and/or discectomy to prepare interspace (other than for

decompression), single interspace; each additional interspace (List

separately in addition to code for primary procedure)

PA 22633 CPT

Arthrodesis, combined posterior or posterolateral technique with

posterior interbody technique including laminectomy and/or

discectomy sufficient to prepare interspace (other than for

decompression), single interspace and segment; lumbar

PA 22634 CPT

Arthrodesis, combined posterior or posterolateral technique with

posterior interbody technique including laminectomy and/or

discectomy sufficient to prepare interspace (other than for

decompression), single interspace and segment; each additional

interspace and segment (List separately in addition to code for primary

procedure)

PA 22800 CPT Arthrodesis, posterior, for spinal deformity, with or without cast; up to

6 vertebral segments

PA 22802 CPT Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to

12 vertebral segments

PA 22804 CPT Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or

more vertebral segments

PA 22808 CPT Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3

vertebral segments

PA 22810 CPT Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7

vertebral segments

PA 22812 CPT Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or

more vertebral segments

PA 22856 CPT

Total disc arthroplasty (artificial disc), anterior approach, including

discectomy with end plate preparation (includes osteophytectomy for

nerve root or spinal cord decompression and microdissection); single

interspace, cervical


5




PA 22857 CPT


discectomy to prepare interspace (other than for decompression),

single interspace, lumbar

PA 22858 CPT


discectomy with end plate preparation (includes osteophytectomy for

nerve root or spinal cord decompression and microdissection); second

level, cervical (List separately in addition to code for primary

procedure)

PA 22861 CPT Revision including replacement of total disc arthroplasty (artificial

disc), anterior approach, single interspace; cervical

PA 22862 CPT Revision including replacement of total disc arthroplasty (artificial

disc), anterior approach, single interspace; lumbar

PA 22864 CPT Removal of total disc arthroplasty (artificial disc), anterior approach,

single interspace; cervical

PA 22865 CPT Removal of total disc arthroplasty (artificial disc), anterior approach,

single interspace; lumbar

PA 27412 CPT Autologous chondrocyte implantation, knee

PA 33285 CPT Insertion, subcutaneous cardiac rhythm monitor, including

programming

PA 33286 CPT Removal, subcutaneous cardiac rhythm monitor

PA 42160 CPT Destruction of lesion, palate or uvula (thermal, cryo or chemical)

PA 43284 CPT

Laparoscopy, surgical, esophageal sphincter augmentation procedure,

placement of sphincter augmentation device (ie, magnetic band),

including cruroplasty when performed

PA 43285 CPT Removal of esophageal sphincter augmentation device

PA 43644 CPT Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass

and Roux-en-Y gastroenterostomy (roux limb 150 cm or less)

PA 43645 CPT Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass

and small intestine reconstruction to l imit absorption


6




PA 43770 CPT

Laparoscopy, surgical, gastric restrictive procedure; placement of

adjustable gastric restrictive device (eg, gastric band and subcutaneous

port components)

PA 43771 CPT Laparoscopy, surgical, gastric restrictive procedure; revision of

adjustable gastric restrictive device component only

PA 43772 CPT Laparoscopy, surgical, gastric restrictive procedure; removal of

adjustable gastric restrictive device component only

PA 43773 CPT Laparoscopy, surgical, gastric restrictive procedure; removal and

replacement of adjustable gastric restrictive device component only

PA 43774 CPT

Laparoscopy, surgical, gastric restrictive procedure; removal of

adjustable gastric restrictive device and subcutaneous port

components

PA 43775 CPT Laparoscopy, surgical, gastric restrictive procedure; longitudinal

gastrectomy (ie, sleeve gastrectomy)

PA 43842 CPT Gastric restrictive procedure, without gastric bypass, for morbid

obesity; vertical-banded gastroplasty

PA 43843 CPT Gastric restrictive procedure, without gastric bypass, for morbid

obesity; other than vertical-banded gastroplasty

PA 43845 CPT

Gastric restrictive procedure with partial gastrectomy, pylorus-

preserving duodenoileostomy and ileoileostomy (50 to 100 cm

common channel) to l imit absorption (biliopancreatic diversion with

duodenal switch)

PA 43846 CPT Gastric restrictive procedure, with gastric bypass for morbid obesity;

with short l imb (150 cm or less) Roux-en-Y gastroenterostomy

PA 43847 CPT Gastric restrictive procedure, with gastric bypass for morbid obesity;

with small intestine reconstruction to l imit absorption

PA 43848 CPT Revision, open, of gastric restrictive procedure for morbid obesity,

other than adjustable gastric restrictive device (separate procedure)

PA 43886 CPT Gastric restrictive procedure, open; revision of subcutaneous port

component only


7




PA 43887 CPT Gastric restrictive procedure, open; removal of subcutaneous port

component only

PA 43888 CPT Gastric restrictive procedure, open; removal and replacement of

subcutaneous port component only

PA 64912 CPT Nerve repair; with nerve allograft, each nerve, first strand (cable)

PA 64913 CPT Nerve repair; with nerve allograft, each additional strand (List


PA 65785 CPT Implantation of intrastromal corneal ring segments

PA 66174 CPT Transluminal dilation of aqueous outflow canal; without retention of

device or stent

PA 66175 CPT Transluminal dilation of aqueous outflow canal; with retention of

device or stent

Notification 70450 CPT Computed tomography, head or brain; without contrast material

Notification 70470 CPT Computed tomography, head or brain; without contrast material,

followed by contrast material(s) and further sections

Notification 70486 CPT Computed tomography, maxillofacial area; without contrast material

Notification 70488 CPT Computed tomography, maxillofacial area; without contrast material,


Notification 70490 CPT Computed tomography, soft tissue neck; without contrast material

Notification 70491 CPT Computed tomography, soft tissue neck; with contrast material(s)

Notification 70492 CPT Computed tomography, soft tissue neck; without contrast material


Notification 70544 CPT Magnetic resonance angiography, head; without contrast material(s)

Notification 70545 CPT Magnetic resonance angiography, head; with contrast material(s)

Notification 70546 CPT Magnetic resonance angiography, head; without contrast material(s),

followed by contrast material(s) and further sequences


8




Notification 70547 CPT Magnetic resonance angiography, neck; without contrast material(s)

Notification 70549 CPT Magnetic resonance angiography, neck; without contrast material(s),

followed by contrast material(s) and further sequences

Notification 70551 CPT Magnetic resonance (eg, proton) imaging, brain (including brain stem);

without contrast material

Notification 70552 CPT Magnetic resonance (eg, proton) imaging, brain (including brain stem);

with contrast material(s)

Notification 70553 CPT

Magnetic resonance (eg, proton) imaging, brain (including brain stem);

without contrast material, followed by contrast material(s) and further

sequences

Notification 71250 CPT Computed tomography, thorax; without contrast material

Notification 71260 CPT Computed tomography, thorax; with contrast material(s)

Notification 71270 CPT Computed tomography, thorax; without contrast material, followed by

contrast material(s) and further sections


Computed tomographic angiography, chest (noncoronary), with

contrast material(s), including noncontrast images, if performed, and

image postprocessing

Notification 72131 CPT Computed tomography, lumbar spine; without contrast material

Notification 72141 CPT Magnetic resonance (eg, proton) imaging, spinal canal and contents,

cervical; without contrast material


cervical; with contrast material(s)


thoracic; without contrast material


thoracic; with contrast material(s)


lumbar; without contrast material


lumbar; with contrast material(s)


9





Magnetic resonance (eg, proton) imaging, spinal canal and contents,


sequences; cervical




sequences; thoracic




sequences; lumbar

Notification 72195 CPT Magnetic resonance (eg, proton) imaging, pelvis; without contrast

material(s)

Notification 72197 CPT Magnetic resonance (eg, proton) imaging, pelvis; without contrast

material(s), followed by contrast material(s) and further sequences

Notification 73221 CPT Magnetic resonance (eg, proton) imaging, any joint of upper extremity;

without contrast material(s)

Notification 73222 CPT Magnetic resonance (eg, proton) imaging, any joint of upper extremity;



Magnetic resonance (eg, proton) imaging, any joint of upper extremity;

without contrast material(s), followed by contrast material(s) and

further sequences

Notification 73225 CPT Magnetic resonance angiography, upper extremity, with or without

contrast material(s)

Notification 73718 CPT Magnetic resonance (eg, proton) imaging, lower extremity other than

joint; without contrast material(s)

Notification 73719 CPT Magnetic resonance (eg, proton) imaging, lower extremity other than

joint; with contrast material(s)

Notification 73721 CPT Magnetic resonance (eg, proton) imaging, any joint of lower extremity;

without contrast material

Notification 73722 CPT Magnetic resonance (eg, proton) imaging, any joint of lower extremity;



10





Magnetic resonance (eg, proton) imaging, any joint of lower extremity;

without contrast material(s), followed by contrast material(s) and

further sequences

Notification 73725 CPT Magnetic resonance angiography, lower extremity, with or without

contrast material(s)

Notification 74150 CPT Computed tomography, abdomen; without contrast material

Notification 74160 CPT Computed tomography, abdomen; with contrast material(s)

Notification 74170 CPT Computed tomography, abdomen; without contrast material, followed

by contrast material(s) and further sections

Notification 74176 CPT Computed tomography, abdomen and pelvis; without contrast

material

Notification 74177 CPT Computed tomography, abdomen and pelvis; with contrast material(s)


Computed tomography, abdomen and pelvis; without contrast

material in one or both body regions, followed by contrast material(s)

and further sections in one or both body regions

Notification 74181 CPT Magnetic resonance (eg, proton) imaging, abdomen; without contrast

material(s)


Magnetic resonance (eg, proton) imaging, abdomen; without contrast

material(s), followed by with contrast material(s) and further

sequences

PA 77520 CPT Proton treatment delivery; simple, without compensation

PA 77522 CPT Proton treatment delivery; simple, with compensation

PA 77523 CPT Proton treatment delivery; intermediate

PA 77525 CPT Proton treatment delivery; complex

PA 78429 CPT

Myocardial imaging, positron emission tomography (PET), metabolic

evaluation study (including ventricular wall motion[s] and/or ejection

fraction[s], when performed), single study; with concurrently acquired

computed tomography transmission scan


11




PA 78430 CPT

Myocardial imaging, positron emission tomography (PET), perfusion

study (including ventricular wall motion[s] and/or ejection fraction[s],

when performed); single study, at rest or stress (exercise or

pharmacologic), with concurrently acquired computed tomography

transmission scan

PA 78431 CPT

Myocardial imaging, positron emission tomography (PET), perfusion

study (including ventricular wall motion[s] and/or ejection fraction[s],

when performed); multiple studies at rest and stress (exercise or

pharmacologic), with concurrently acquired computed tomography

transmission scan

PA 78432 CPT

Myocardial imaging, positron emission tomography (PET), combined

perfusion with metabolic evaluation study (including ventricular wall

motion[s] and/or ejection fraction[s], when performed), dual

radiotracer (eg, myocardial viability);

PA 78433 CPT

Myocardial imaging, positron emission tomography (PET), combined

perfusion with metabolic evaluation study (including ventricular wall

motion[s] and/or ejection fraction[s], when performed), dual

radiotracer (eg, myocardial viability); with concurrently acquired

computed tomography transmission scan


Positron emission tomography (PET) with concurrently acquired

computed tomography (CT) for attenuation correction and anatomical

localization imaging; skull base to mid-thigh

PA 78830 CPT

Radiopharmaceutical localization of tumor, inflammatory process or

distribution of radiopharmaceutical agent(s) (includes vascular flow

and blood pool imaging, when performed); tomographic (SPECT) with

concurrently acquired computed tomography (CT) transmission scan

for anatomical review, localization and determination/detection of

pathology, single area (eg, head, neck, chest, pelvis), single day

imaging

PA 78831 CPT



and blood pool imaging, when performed); tomographic (SPECT),

minimum 2 areas (eg, pelvis and knees, abdomen and pelvis), single

day imaging, or single area imaging over 2 or more days


12




PA 78832 CPT



and blood pool imaging, when performed); tomographic (SPECT) with

concurrently acquired computed tomography (CT) transmission scan

for anatomical review, localization and determination/detection of

pathology, minimum 2 areas (eg, pelvis and knees, abdomen and

pelvis), single day imaging, or single area imaging over 2 or more days

PA 81105 CPT

Human Platelet Antigen 1 genotyping (HPA-1), ITGB3 (integrin, beta 3

[platelet glycoprotein IIIa], antigen CD61 [GPIIIa]) (eg, neonatal

alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene

analysis, common variant, HPA-1a/b (L33P)

PA 81106 CPT

Human Platelet Antigen 2 genotyping (HPA-2), GP1BA (glycoprotein Ib

[platelet], alpha polypeptide [GPIba]) (eg, neonatal alloimmune

thrombocytopenia [NAIT], post-transfusion purpura), gene analysis,

common variant, HPA-2a/b (T145M)

PA 81107 CPT

Human Platelet Antigen 3 genotyping (HPA-3), ITGA2B (integrin, alpha

2b [platelet glycoprotein IIb of IIb/IIIa complex], antigen CD41 [GPIIb])

(eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion

purpura), gene analysis, common variant, HPA-3a/b (I843S)

PA 81108 CPT

Human Platelet Antigen 4 genotyping (HPA-4), ITGB3 (integrin, beta 3

[platelet glycoprotein IIIa], antigen CD61 [GPIIIa]) (eg, neonatal


analysis, common variant, HPA-4a/b (R143Q)

PA 81109 CPT

Human Platelet Antigen 5 genotyping (HPA-5), ITGA2 (integrin, alpha 2

[CD49B, alpha 2 subunit of VLA-2 receptor] [GPIa]) (eg, neonatal


analysis, common variant (eg, HPA-5a/b (K505E))

PA 81110 CPT

Human Platelet Antigen 6 genotyping (HPA-6w), ITGB3 (integrin, beta 3

[platelet glycoprotein IIIa, antigen CD61] [GPIIIa]) (eg, neonatal


analysis, common variant, HPA-6a/b (R489Q)


13




PA 81111 CPT

Human Platelet Antigen 9 genotyping (HPA-9w), ITGA2B (integrin,

alpha 2b [platelet glycoprotein IIb of IIb/IIIa complex, antigen CD41]

[GPIIb]) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-

transfusion purpura), gene analysis, common variant, HPA-9a/b

(V837M)

PA 81112 CPT

Human Platelet Antigen 15 genotyping (HPA-15), CD109 (CD109

molecule) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-

transfusion purpura), gene analysis, common variant, HPA-15a/b

(S682Y)

PA 81120 CPT IDH1 (isocitrate dehydrogenase 1 [NADP+], soluble) (eg, glioma),

common variants (eg, R132H, R132C)

PA 81121 CPT IDH2 (isocitrate dehydrogenase 2 [NADP+], mitochondrial) (eg,

glioma), common variants (eg, R140W, R172M)

PA 81161 CPT DMD (dystrophin) (eg, Duchenne/Becker muscular dystrophy) deletion

analysis, and duplication analysis, if performed

PA 81162 CPT

BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and

ovarian cancer) gene analysis; full sequence analysis and full

duplication/deletion analysis

PA 81163 CPT

BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair

associated) (eg, hereditary breast and ovarian cancer) gene analysis;

full sequence analysis

PA 81164 CPT

BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair

associated) (eg, hereditary breast and ovarian cancer) gene analysis;

full duplication/deletion analysis (ie, detection of large gene

rearrangements)

PA 81165 CPT BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and

ovarian cancer) gene analysis; full sequence analysis

PA 81166 CPT

BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and

ovarian cancer) gene analysis; full duplication/deletion analysis (ie,

detection of large gene rearrangements)

PA 81167 CPT

BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and

ovarian cancer) gene analysis; full duplication/deletion analysis (ie,

detection of large gene rearrangements)


14




PA 81171 CPT

AFF2 (AF4/FMR2 family, member 2 [FMR2]) (eg, fragile X mental

retardation 2 [FRAXE]) gene analysis; evaluation to detect abnormal

(eg, expanded) alleles

PA 81172 CPT

AFF2 (AF4/FMR2 family, member 2 [FMR2]) (eg, fragile X mental

retardation 2 [FRAXE]) gene analysis; characterization of alleles (eg,

expanded size and methylation status)

PA 81173 CPT

AR (androgen receptor) (eg, spinal and bulbar muscular atrophy,

Kennedy disease, X chromosome inactivation) gene analysis; full gene

sequence

PA 81174 CPT


Kennedy disease, X chromosome inactivation) gene analysis; known

familial variant

PA 81175 CPT

ASXL1 (additional sex combs like 1, transcriptional regulator) (eg,

myelodysplastic syndrome, myeloproliferative neoplasms, chronic

myelomonocytic leukemia), gene analysis; full gene sequence

PA 81176 CPT

ASXL1 (additional sex combs like 1, transcriptional regulator) (eg,

myelodysplastic syndrome, myeloproliferative neoplasms, chronic

myelomonocytic leukemia), gene analysis; targeted sequence analysis

(eg, exon 12)

PA 81177 CPT ATN1 (atrophin 1) (eg, dentatorubral-pallidoluysian atrophy) gene

analysis, evaluation to detect abnormal (eg, expanded) alleles

PA 81178 CPT ATXN1 (ataxin 1) (eg, spinocerebellar ataxia) gene analysis, evaluation

to detect abnormal (eg, expanded) alleles



PA 81180 CPT ATXN3 (ataxin 3) (eg, spinocerebellar ataxia, Machado-Joseph disease)

gene analysis, evaluation to detect abnormal (eg, expanded) alleles



PA 81182 CPT

ATXN8OS (ATXN8 opposite strand [non-protein coding]) (eg,

spinocerebellar ataxia) gene analysis, evaluation to detect abnormal



15




PA 81183 CPT ATXN10 (ataxin 10) (eg, spinocerebellar ataxia) gene analysis,

evaluation to detect abnormal (eg, expanded) alleles

PA 81184 CPT

CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg,

spinocerebellar ataxia) gene analysis; evaluation to detect abnormal


PA 81185 CPT CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg,

spinocerebellar ataxia) gene analysis; full gene sequence

PA 81186 CPT CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg,

spinocerebellar ataxia) gene analysis; known familial variant

PA 81187 CPT

CNBP (CCHC-type zinc finger nucleic acid binding protein) (eg,

myotonic dystrophy type 2) gene analysis, evaluation to detect

abnormal (eg, expanded) alleles

PA 81188 CPT CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis;

evaluation to detect abnormal (eg, expanded) alleles

PA 81189 CPT CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; full

gene sequence

PA 81190 CPT CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis;

known familial variant(s)

PA 81200 CPT ASPA (aspartoacylase) (eg, Canavan disease) gene analysis, common

variants (eg, E285A, Y231X)

PA 81201 CPT APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis

[FAP], attenuated FAP) gene analysis; full gene sequence


[FAP], attenuated FAP) gene analysis; known familial variants


[FAP], attenuated FAP) gene analysis; duplication/deletion variants

PA 81204 CPT


Kennedy disease, X chromosome inactivation) gene analysis;

characterization of alleles (eg, expanded size or methylation status)


16




PA 81205 CPT

BCKDHB (branched-chain keto acid dehydrogenase E1, beta

polypeptide) (eg, maple syrup urine disease) gene analysis, common

variants (eg, R183P, G278S, E422X)

PA 81206 CPT BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation

analysis; major breakpoint, qualitative or quantitative


analysis; minor breakpoint, qualitative or quantitative


analysis; other breakpoint, qualitative or quantitative

PA 81209 CPT BLM (Bloom syndrome, RecQ helicase-like) (eg, Bloom syndrome) gene

analysis, 2281del6ins7 variant

PA 81210 CPT BRAF (B-Raf proto-oncogene, serine/threonine kinase) (eg, colon

cancer, melanoma), gene analysis, V600 variant(s)

PA 81212 CPT BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and

ovarian cancer) gene analysis; 185delAG, 5385insC, 6174delT variants

PA 81215 CPT BRCA1 (breast cancer 1) (eg, hereditary breast and ovarian cancer)

gene analysis; known familial variant


gene analysis; full sequence analysis


gene analysis; known familial variant

PA 81218 CPT CEBPA (CCAAT/enhancer binding protein [C/EBP], alpha) (eg, acute

myeloid leukemia), gene analysis, full gene sequence

PA 81219 CPT CALR (calreticulin) (eg, myeloproliferative disorders), gene analysis,

common variants in exon 9

PA 81220 CPT CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic

fibrosis) gene analysis; common variants (eg, ACMG/ACOG guidelines)


fibrosis) gene analysis; known familial variants


17





fibrosis) gene analysis; duplication/deletion variants


fibrosis) gene analysis; full gene sequence


fibrosis) gene analysis; intron 8 poly-T analysis (eg, male infertility)

PA 81225 CPT

CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19) (eg,

drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *8,

*17)

PA 81226 CPT

CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg,

drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *5,

*6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN)

PA 81227 CPT CYP2C9 (cytochrome P450, family 2, subfamily C, polypeptide 9) (eg,

drug metabolism), gene analysis, common variants (eg, *2, *3, *5, *6)

PA 81228 CPT

Cytogenomic constitutional (genome-wide) microarray analysis;

interrogation of genomic regions for copy number variants (eg,

bacterial artificial chromosome [BAC] or oligo-based comparative

genomic hybridization [CGH] microarray analysis)

PA 81229 CPT

Cytogenomic constitutional (genome-wide) microarray analysis;

interrogation of genomic regions for copy number and single

nucleotide polymorphism (SNP) variants for chromosomal

abnormalities

PA 81230 CPT CYP3A4 (cytochrome P450 family 3 subfamily A member 4) (eg, drug

metabolism), gene analysis, common variant(s) (eg, *2, *22)

PA 81231 CPT

CYP3A5 (cytochrome P450 family 3 subfamily A member 5) (eg, drug

metabolism), gene analysis, common variants (eg, *2, *3, *4, *5, *6,

*7)

PA 81232 CPT

DPYD (dihydropyrimidine dehydrogenase) (eg, 5-fluorouracil/5-FU and

capecitabine drug metabolism), gene analysis, common variant(s) (eg,

*2A, *4, *5, *6)


18




PA 81233 CPT BTK (Bruton's tyrosine kinase) (eg, chronic lymphocytic leukemia) gene

analysis, common variants (eg, C481S, C481R, C481F)

PA 81234 CPT DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene

analysis; evaluation to detect abnormal (expanded) alleles

PA 81235 CPT

EGFR (epidermal growth factor receptor) (eg, non-small cell lung

cancer) gene analysis, common variants (eg, exon 19 LREA deletion,

L858R, T790M, G719A, G719S, L861Q)

PA 81236 CPT

EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit)

(eg, myelodysplastic syndrome, myeloproliferative neoplasms) gene

analysis, full gene sequence

PA 81237 CPT

EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit)

(eg, diffuse large B-cell lymphoma) gene analysis, common variant(s)

(eg, codon 646)

PA 81238 CPT F9 (coagulation factor IX) (eg, hemophilia B), full gene sequence

PA 81239 CPT DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene

analysis; characterization of alleles (eg, expanded size)

PA 81242 CPT FANCC (Fanconi anemia, complementation group C) (eg, Fanconi

anemia, type C) gene analysis, common variant (eg, IVS4+4A>T)

PA 81243 CPT FMR1 (fragile X mental retardation 1) (eg, fragile X mental retardation)

gene analysis; evaluation to detect abnormal (eg, expanded) alleles

PA 81244 CPT

FMR1 (fragile X mental retardation 1) (eg, fragile X mental retardation)

gene analysis; characterization of alleles (eg, expanded size and

methylation status)

PA 81245 CPT FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia), gene

analysis; internal tandem duplication (ITD) variants (ie, exons 14, 15)

PA 81246 CPT FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia), gene

analysis; tyrosine kinase domain (TKD) variants (eg, D835, I836)

PA 81247 CPT G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia,

jaundice), gene analysis; common variant(s) (eg, A, A-)


19





jaundice), gene analysis; known familial variant(s)


jaundice), gene analysis; full gene sequence

PA 81250 CPT

G6PC (glucose-6-phosphatase, catalytic subunit) (eg, Glycogen storage

disease, type 1a, von Gierke disease) gene analysis, common variants

(eg, R83C, Q347X)

PA 81251 CPT GBA (GLUCOSIDASE, BETA, ACID) (EG, GAUCHER DISEASE) GENE

ANALYSIS, COMMON VARIANTS (EG, L444P IVS2+1G>A)

PA 81252 CPT GJB2 (gap junction protein, beta 2, 26kDa, connexin 26) (eg,

nonsyndromic hearing loss) gene analysis; full gene sequence

PA 81253 CPT GJB2 (gap junction protein, beta 2, 26kDa, connexin 26) (eg,

nonsyndromic hearing loss) gene analysis; known familial variants

PA 81254 CPT

GJB6 (gap junction protein, beta 6, 30kDa, connexin 30) (eg,

nonsyndromic hearing loss) gene analysis, common variants (eg, 309kb

[del(GJB6-D13S1830)] and 232kb [del(GJB6-D13S1854)])

PA 81255 CPT HEXA (hexosaminidase A [alpha polypeptide]) (eg, Tay-Sachs disease)

gene analysis, common variants (eg, 1278insTATC, 1421+1G>C, G269S)

PA 81256 CPT HFE (hemochromatosis) (eg, hereditary hemochromatosis) gene

analysis, common variants (eg, C282Y, H63D)

PA 81257 CPT

HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia,

Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis, for

common deletions or variant (eg, Southeast Asian, Thai, Fi lipino,

Mediterranean, alpha3.7, alpha4.2, alpha20.5, and Constant Spring)

PA 81258 CPT


Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; known

familial variant

PA 81259 CPT


Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; full

gene sequence


20




PA 81260 CPT

IKBKAP (inhibitor of kappa light polypeptide gene enhancer in B-cells,

kinase complex-associated protein) (eg, familial dysautonomia) gene

analysis, common variants (eg, 2507+6T>C, R696P)

PA 81261 CPT

IGH@ (Immunoglobulin heavy chain locus) (eg, leukemias and

lymphomas, B-cell), gene rearrangement analysis to detect abnormal

clonal population(s); amplified methodology (eg, polymerase chain

reaction)

PA 81262 CPT

IGH@ (Immunoglobulin heavy chain locus) (eg, leukemias and

lymphomas, B-cell), gene rearrangement analysis to detect abnormal

clonal population(s); direct probe methodology (eg, Southern blot)

PA 81263 CPT IGH@ (Immunoglobulin heavy chain locus) (eg, leukemia and

lymphoma, B-cell), variable region somatic mutation analysis

PA 81264 CPT

IGK@ (Immunoglobulin kappa light chain locus) (eg, leukemia and

lymphoma, B-cell), gene rearrangement analysis, evaluation to detect

abnormal clonal population(s)

PA 81265 CPT

Comparative analysis using Short Tandem Repeat (STR) markers;

patient and comparative specimen (eg, pre-transplant recipient and

donor germline testing, post-transplant non-hematopoietic recipient

germline [eg, buccal swab or other germline tissue sample] and donor

testing, twin zygosity testing, or maternal cell contamination of fetal

cells)

PA 81266 CPT

Comparative analysis using Short Tandem Repeat (STR) markers; each

additional specimen (eg, additional cord blood donor, additional fetal

samples from different cultures, or additional zygosity in multiple birth

pregnancies) (List separately in addition to code for primary

procedure)

PA 81267 CPT

Chimerism (engraftment) analysis, post transplantation specimen (eg,

hematopoietic stem cell), includes comparison to previously

performed baseline analyses; without cell selection

PA 81268 CPT

Chimerism (engraftment) analysis, post transplantation specimen (eg,

hematopoietic stem cell), includes comparison to previously

performed baseline analyses; with cell selection (eg, CD3, CD33), each

cell type


21




PA 81269 CPT


Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis;

duplication/deletion variants

PA 81270 CPT JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) gene analysis,

p.Val617Phe (V617F) variant

PA 81271 CPT HTT (huntingtin) (eg, Huntington disease) gene analysis; evaluation to

detect abnormal (eg, expanded) alleles

PA 81272 CPT

KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog)

(eg, gastrointestinal stromal tumor [GIST], acute myeloid leukemia,

melanoma), gene analysis, targeted sequence analysis (eg, exons 8, 11,

13, 17, 18)

PA 81273 CPT KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog)

(eg, mastocytosis), gene analysis, D816 variant(s)

PA 81274 CPT HTT (huntingtin) (eg, Huntington disease) gene analysis;

characterization of alleles (eg, expanded size)

PA 81275 CPT KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg, carcinoma)

gene analysis; variants in exon 2 (eg, codons 12 and 13)

PA 81276 CPT KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg, carcinoma)

gene analysis; additional variant(s) (eg, codon 61, codon 146)

PA 81277 CPT

Cytogenomic neoplasia (genome-wide) microarray analysis,

interrogation of genomic regions for copy number and loss-of-

heterozygosity variants for chromosomal abnormalities

PA 81283 CPT IFNL3 (interferon, lambda 3) (eg, drug response), gene analysis,

rs12979860 variant

PA 81284 CPT FXN (frataxin) (eg, Friedreich ataxia) gene analysis; evaluation to

detect abnormal (expanded) alleles

PA 81285 CPT FXN (frataxin) (eg, Friedreich ataxia) gene analysis; characterization of

alleles (eg, expanded size)

PA 81286 CPT FXN (frataxin) (eg, Friedreich ataxia) gene analysis; full gene sequence

PA 81287 CPT MGMT (O-6-methylguanine-DNA methyltransferase) (eg, glioblastoma

multiforme), methylation analysis


22




PA 81288 CPT

MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg,

hereditary non-polyposis colorectal cancer, Lynch syndrome) gene

analysis; promoter methylation analysis

PA 81289 CPT FXN (frataxin) (eg, Friedreich ataxia) gene analysis; known familial

variant(s)

PA 81290 CPT MCOLN1 (mucolipin 1) (eg, Mucolipidosis, type IV) gene analysis,

common variants (eg, IVS3-2A>G, del6.4kb)

PA 81292 CPT



analysis; full sequence analysis

PA 81293 CPT



analysis; known familial variants

PA 81294 CPT



analysis; duplication/deletion variants

PA 81295 CPT

MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg,



PA 81296 CPT




PA 81297 CPT




PA 81298 CPT

MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non-polyposis

colorectal cancer, Lynch syndrome) gene analysis; full sequence

analysis

PA 81299 CPT


colorectal cancer, Lynch syndrome) gene analysis; known familial

variants

PA 81300 CPT


colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion

variants


23




PA 81301 CPT

Microsatellite instability analysis (eg, hereditary non-polyposis

colorectal cancer, Lynch syndrome) of markers for mismatch repair

deficiency (eg, BAT25, BAT26), includes comparison of neoplastic and

normal tissue, if performed

PA 81302 CPT MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome) gene



analysis; known familial variant



PA 81305 CPT

MYD88 (myeloid differentiation primary response 88) (eg,

Waldenstrom's macroglobulinemia, lymphoplasmacytic leukemia)

gene analysis, p.Leu265Pro (L265P) variant

PA 81306 CPT NUDT15 (nudix hydrolase 15) (eg, drug metabolism) gene analysis,

common variant(s) (eg, *2, *3, *4, *5, *6)

PA 81307 CPT PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic

cancer) gene analysis; full gene sequence

PA 81308 CPT PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic

cancer) gene analysis; known familial variant

PA 81309 CPT

PIK3CA (phosphatidylinositol-4, 5-biphosphate 3-kinase, catalytic

subunit alpha) (eg, colorectal and breast cancer) gene analysis,

targeted sequence analysis (eg, exons 7, 9, 20)

PA 81310 CPT NPM1 (nucleophosmin) (eg, acute myeloid leukemia) gene analysis,

exon 12 variants

PA 81311 CPT

NRAS (neuroblastoma RAS viral [v-ras] oncogene homolog) (eg,

colorectal carcinoma), gene analysis, variants in exon 2 (eg, codons 12

and 13) and exon 3 (eg, codon 61)

PA 81312 CPT

PABPN1 (poly[A] binding protein nuclear 1) (eg, oculopharyngeal

muscular dystrophy) gene analysis, evaluation to detect abnormal (eg,

expanded) alleles

PA 81313 CPT

PCA3/KLK3 (prostate cancer antigen 3 [non-protein coding]/kallikrein-

related peptidase 3 [prostate specific antigen]) ratio (eg, prostate

cancer)


24




PA 81314 CPT

PDGFRA (platelet-derived growth factor receptor, alpha polypeptide)

(eg, gastrointestinal stromal tumor [GIST]), gene analysis, targeted

sequence analysis (eg, exons 12, 18)

PA 81315 CPT

PML/RARalpha, (t(15;17)), (promyelocytic leukemia/retinoic acid

receptor alpha) (eg, promyelocytic leukemia) translocation analysis;

common breakpoints (eg, intron 3 and intron 6), qualitative or

quantitative

PA 81316 CPT

PML/RARalpha, (t(15;17)), (promyelocytic leukemia/retinoic acid

receptor alpha) (eg, promyelocytic leukemia) translocation analysis;

single breakpoint (eg, intron 3, intron 6 or exon 6), qualitative or

quantitative

PA 81317 CPT

PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg,



PA 81318 CPT




PA 81319 CPT




PA 81320 CPT PLCG2 (phospholipase C gamma 2) (eg, chronic lymphocytic leukemia)

gene analysis, common variants (eg, R665W, S707F, L845F)

PA 81321 CPT PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN

hamartoma tumor syndrome) gene analysis; full sequence analysis

PA 81322 CPT PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN

hamartoma tumor syndrome) gene analysis; known familial variant

PA 81323 CPT

PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN

hamartoma tumor syndrome) gene analysis; duplication/deletion

variant

PA 81324 CPT

PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth,

hereditary neuropathy with l iability to pressure palsies) gene analysis;

duplication/deletion analysis


25




PA 81325 CPT



full sequence analysis

PA 81326 CPT



known familial variant

PA 81328 CPT

SLCO1B1 (solute carrier organic anion transporter family, member

1B1) (eg, adverse drug reaction), gene analysis, common variant(s) (eg,

*5)

PA 81329 CPT

SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular

atrophy) gene analysis; dosage/deletion analysis (eg, carrier testing),

includes SMN2 (survival of motor neuron 2, centromeric) analysis, if

performed

PA 81330 CPT

SMPD1(sphingomyelin phosphodiesterase 1, acid lysosomal) (eg,

Niemann-Pick disease, Type A) gene analysis, common variants (eg,

R496L, L302P, fsP330)

PA 81331 CPT

SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and

ubiquitin protein ligase E3A) (eg, Prader-Willi syndrome and/or

Angelman syndrome), methylation analysis

PA 81332 CPT

SERPINA1 (serpin peptidase inhibitor, clade A, alpha-1 antiproteinase,

antitrypsin, member 1) (eg, alpha-1-antitrypsin deficiency), gene

analysis, common variants (eg, *S and *Z)

PA 81333 CPT

TGFBI (transforming growth factor beta-induced) (eg, corneal

dystrophy) gene analysis, common variants (eg, R124H, R124C, R124L,

R555W, R555Q)

PA 81334 CPT

RUNX1 (runt related transcription factor 1) (eg, acute myeloid

leukemia, familial platelet disorder with associated myeloid

malignancy), gene analysis, targeted sequence analysis (eg, exons 3-8)

PA 81335 CPT TPMT (thiopurine S-methyltransferase) (eg, drug metabolism), gene

analysis, common variants (eg, *2, *3)

PA 81336 CPT SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular

atrophy) gene analysis; full gene sequence


26




PA 81337 CPT SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular

atrophy) gene analysis; known familial sequence variant(s)

PA 81340 CPT

TRB@ (T cell antigen receptor, beta) (eg, leukemia and lymphoma),

gene rearrangement analysis to detect abnormal clonal population(s);

using amplification methodology (eg, polymerase chain reaction)

PA 81341 CPT

TRB@ (T cell antigen receptor, beta) (eg, leukemia and lymphoma),

gene rearrangement analysis to detect abnormal clonal population(s);

using direct probe methodology (eg, Southern blot)

PA 81342 CPT

TRG@ (T cell antigen receptor, gamma) (eg, leukemia and lymphoma),

gene rearrangement analysis, evaluation to detect abnormal clonal

population(s)

PA 81343 CPT

PPP2R2B (protein phosphatase 2 regulatory subunit Bbeta) (eg,

spinocerebellar ataxia) gene analysis, evaluation to detect abnormal


PA 81344 CPT TBP (TATA box binding protein) (eg, spinocerebellar ataxia) gene

analysis, evaluation to detect abnormal (eg, expanded) alleles

PA 81345 CPT

TERT (telomerase reverse transcriptase) (eg, thyroid carcinoma,

glioblastoma multiforme) gene analysis, targeted sequence analysis

(eg, promoter region)

PA 81346 CPT

TYMS (thymidylate synthetase) (eg, 5-fluorouracil/5-FU drug

metabolism), gene analysis, common variant(s) (eg, tandem repeat

variant)

PA 81350 CPT

UGT1A1 (UDP glucuronosyltransferase 1 family, polypeptide A1) (eg,

irinotecan metabolism), gene analysis, common variants (eg, *28, *36,

*37)

PA 81355 CPT

VKORC1 (vitamin K epoxide reductase complex, subunit 1) (eg,

warfarin metabolism), gene analysis, common variant(s) (eg, -

1639G>A, c.173+1000C>T)

PA 81361 CPT

HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta

thalassemia, hemoglobinopathy); common variant(s) (eg, HbS, HbC,

HbE)


27




PA 81362 CPT HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta

thalassemia, hemoglobinopathy); known familial variant(s)


thalassemia, hemoglobinopathy); duplication/deletion variant(s)


thalassemia, hemoglobinopathy); full gene sequence

PA 81370 CPT HLA Class I and II typing, low resolution (eg, antigen equivalents); HLA-

A, -B, -C, -DRB1/3/4/5, and -DQB1

PA 81371 CPT HLA Class I and II typing, low resolution (eg, antigen equivalents); HLA-

A, -B, and -DRB1 (eg, verification typing)

PA 81372 CPT HLA Class I typing, low resolution (eg, antigen equivalents); complete

(ie, HLA-A, -B, and -C)

PA 81373 CPT HLA Class I typing, low resolution (eg, antigen equivalents); one locus

(eg, HLA-A, -B, or -C), each

PA 81374 CPT HLA Class I typing, low resolution (eg, antigen equivalents); one

antigen equivalent (eg, B*27), each

PA 81375 CPT HLA Class II typing, low resolution (eg, antigen equivalents); HLA-

DRB1/3/4/5 and -DQB1

PA 81376 CPT HLA Class II typing, low resolution (eg, antigen equivalents); one locus

(eg, HLA-DRB1, -DRB3/4/5, -DQB1, -DQA1, -DPB1, or -DPA1), each

PA 81377 CPT HLA Class II typing, low resolution (eg, antigen equivalents); one

antigen equivalent, each

PA 81378 CPT HLA Class I and II typing, high resolution (ie, alleles or allele groups),

HLA-A, -B, -C, and -DRB1

PA 81379 CPT HLA Class I typing, high resolution (ie, alleles or allele groups);

complete (ie, HLA-A, -B, and -C)

PA 81380 CPT HLA Class I typing, high resolution (ie, alleles or allele groups); one

locus (eg, HLA-A, -B, or -C), each

PA 81381 CPT HLA Class I typing, high resolution (ie, alleles or allele groups); one

allele or allele group (eg, B*57:01P), each


28




PA 81382 CPT

HLA Class II typing, high resolution (ie, alleles or allele groups); one

locus (eg, HLA-DRB1, -DRB3/4/5, -DQB1, -DQA1, -DPB1, or -DPA1),

each

PA 81383 CPT HLA Class II typing, high resolution (ie, alleles or allele groups); one

allele or allele group (eg, HLA-DQB1*06:02P), each

PA 81400 CPT

Molecular pathology procedure, Level 1(eg, identification of single

germline variant [eg, SNP] by techniques such as restriction enzyme

digestion or melt curve analysis)

PA 81401 CPT

Molecular pathology procedure, Level 2 (eg, 2-10 SNPs, 1 methylated

variant, or 1 somatic variant [typically using nonsequencing target

variant analysis], or detection of a dynamic mutation disorder/triplet

repeat)

PA 81402 CPT

Molecular pathology procedure, Level 3 (eg, >10 SNPs, 2-10

methylated variants, or 2-10 somatic variants [typically using non-

sequencing target variant analysis], immunoglobulin and T-cell

receptor gene rearrangements, duplication/deletion variants of 1

exon, loss of heterozygosity [LOH], uniparental disomy [UPD])

PA 81403 CPT

Molecular pathology procedure, Level 4 (eg, analysis of single exon by

DNA sequence analysis, analysis of >10 amplicons using multiplex PCR

in 2 or more independent reactions, mutation scanning or

duplication/deletion variants of 2-5 exons)

PA 81404 CPT

Molecular pathology procedure, Level 5 (eg, analysis of 2-5 exons by

DNA sequence analysis, mutation scanning or duplication/deletion

variants of 6-10 exons, or characterization of a dynamic mutation

disorder/triplet repeat by Southern blot analysis)

PA 81405 CPT



variants of 11-25 exons, regionally targeted cytogenomic array

analysis)

PA 81406 CPT



variants of 26-50 exons, cytogenomic array analysis for neoplasia)


29




PA 81407 CPT



variants of >50 exons, sequence analysis of multiple genes on one

platform)

PA 81408 CPT Molecular pathology procedure, Level 9 (eg, analysis of >50 exons in a

single gene by DNA sequence analysis)

PA 81410 CPT

Aortic dysfunction or dilation (eg, Marfan syndrome, Loeys Dietz

syndrome, Ehler Danlos syndrome type IV, arterial tortuosity

syndrome); genomic sequence analysis panel, must include sequencing

of at least 9 genes, including FBN1, TGFBR1, TGFBR2, COL3A1, MYH11,

ACTA2, SLC2A10, SMAD3, and MYLK

PA 81411 CPT

Aortic dysfunction or dilation (eg, Marfan syndrome, Loeys Dietz

syndrome, Ehler Danlos syndrome type IV, arterial tortuosity

syndrome); duplication/deletion analysis panel, must include analyses

for TGFBR1, TGFBR2, MYH11, and COL3A1

PA 81412 CPT

Ashkenazi Jewish associated disorders (eg, Bloom syndrome, Canavan

disease, cystic fibrosis, familial dysautonomia, Fanconi anemia group C,

Gaucher disease, Tay-Sachs disease), genomic sequence analysis panel,

must include sequencing of at least 9 genes, including ASPA, BLM,

CFTR, FANCC, GBA, HEXA, IKBKAP, MCOLN1, and SMPD1

PA 81413 CPT

Cardiac ion channelopathies (eg, Brugada syndrome, long QT

syndrome, short QT syndrome, catecholaminergic polymorphic

ventricular tachycardia); genomic sequence analysis panel, must

include sequencing of at least 10 genes, including ANK2, CASQ2, CAV3,

KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, and SCN5A

PA 81414 CPT

Cardiac ion channelopathies (eg, Brugada syndrome, long QT

syndrome, short QT syndrome, catecholaminergic polymorphic

ventricular tachycardia); duplication/deletion gene analysis panel,

must include analysis of at least 2 genes, including KCNH2 and KCNQ1

PA 81415 CPT Exome (eg, unexplained constitutional or heritable disorder or

syndrome); sequence analysis


30




PA 81416 CPT

Exome (eg, unexplained constitutional or heritable disorder or

syndrome); sequence analysis, each comparator exome (eg, parents,

siblings) (List separately in addition to code for primary procedure)

PA 81417 CPT

Exome (eg, unexplained constitutional or heritable disorder or

syndrome); re-evaluation of previously obtained exome sequence (eg,

updated knowledge or unrelated condition/syndrome)

PA 81420 CPT

Fetal chromosomal aneuploidy (eg, trisomy 21, monosomy X) genomic

sequence analysis panel, circulating cell-free fetal DNA in maternal

blood, must include analysis of chromosomes 13, 18, and 21

PA 81422 CPT

Fetal chromosomal microdeletion(s) genomic sequence analysis (eg,

DiGeorge syndrome, Cri-du-chat syndrome), circulating cell-free fetal

DNA in maternal blood

PA 81425 CPT Genome (eg, unexplained constitutional or heritable disorder or

syndrome); sequence analysis

PA 81426 CPT

Genome (eg, unexplained constitutional or heritable disorder or

syndrome); sequence analysis, each comparator genome (eg, parents,

siblings) (List separately in addition to code for primary procedure)

PA 81427 CPT

Genome (eg, unexplained constitutional or heritable disorder or

syndrome); re-evaluation of previously obtained genome sequence

(eg, updated knowledge or unrelated condition/syndrome)

PA 81430 CPT

Hearing loss (eg, nonsyndromic hearing loss, Usher syndrome, Pendred

syndrome); genomic sequence analysis panel, must include sequencing

of at least 60 genes, including CDH23, CLRN1, GJB2, GPR98, MTRNR1,

MYO7A, MYO15A, PCDH15, OTOF, SLC26A4, TMC1, TMPRSS3, USH1C,

USH1G, USH2A, and WFS1

PA 81431 CPT

Hearing loss (eg, nonsyndromic hearing loss, Usher syndrome, Pendred

syndrome); duplication/deletion analysis panel, must include copy

number analyses for STRC and DFNB1 deletions in GJB2 and GJB6

genes


31




PA 81432 CPT

Hereditary breast cancer-related disorders (eg, hereditary breast

cancer, hereditary ovarian cancer, hereditary endometrial cancer);

genomic sequence analysis panel, must include sequencing of at least

14 genes, including ATM, BRCA1, BRCA2, BRIP1, CDH1, MLH1, MSH2,

MSH6, NBN, PALB2, PTEN, RAD51C, STK11, and TP53

PA 81433 CPT

Hereditary breast cancer-related disorders (eg, hereditary breast

cancer, hereditary ovarian cancer, hereditary endometrial cancer);

duplication/deletion analysis panel, must include analyses for BRCA1,

BRCA2, MLH1, MSH2, and STK11

PA 81434 CPT

Hereditary retinal disorders (eg, retinitis pigmentosa, Leber congenital

amaurosis, cone-rod dystrophy), genomic sequence analysis panel,

must include sequencing of at least 15 genes, including ABCA4,

CNGA1, CRB1, EYS, PDE6A, PDE6B, PRPF31, PRPH2, RDH12, RHO, RP1,

RP2, RPE65, RPGR, and USH2A

PA 81435 CPT

Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN

hamartoma syndrome, Cowden syndrome, familial adenomatosis

polyposis); genomic sequence analysis panel, must include sequencing

of at least 10 genes, including APC, BMPR1A, CDH1, MLH1, MSH2,

MSH6, MUTYH, PTEN, SMAD4, and STK11

PA 81436 CPT

Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN

hamartoma syndrome, Cowden syndrome, familial adenomatosis

polyposis); duplication/deletion analysis panel, must include analysis

of at least 5 genes, including MLH1, MSH2, EPCAM, SMAD4, and STK11

PA 81437 CPT

Hereditary neuroendocrine tumor disorders (eg, medullary thyroid

carcinoma, parathyroid carcinoma, malignant pheochromocytoma or

paraganglioma); genomic sequence analysis panel, must include

sequencing of at least 6 genes, including MAX, SDHB, SDHC, SDHD,

TMEM127, and VHL

PA 81438 CPT

Hereditary neuroendocrine tumor disorders (eg, medullary thyroid

carcinoma, parathyroid carcinoma, malignant pheochromocytoma or

paraganglioma); duplication/deletion analysis panel, must include

analyses for SDHB, SDHC, SDHD, and VHL


32




PA 81439 CPT

Inherited cardiomyopathy (eg, hypertrophic cardiomyopathy, dilated

cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy)

genomic sequence analysis panel, must include sequencing of at least

5 genes, including DSG2, MYBPC3, MYH7, PKP2, and TTN

PA 81440 CPT

Nuclear encoded mitochondrial genes (eg, neurologic or myopathic

phenotypes), genomic sequence panel, must include analysis of at

least 100 genes, including BCS1L, C10orf2, COQ2, COX10, DGUOK,

MPV17, OPA1, PDSS2, POLG, POLG2, RRM2B, SCO1, SCO2, SLC25A4,

SUCLA2, SUCLG1, TAZ, TK2, and TYMP

PA 81442 CPT

Noonan spectrum disorders (eg, Noonan syndrome, cardio-facio-

cutaneous syndrome, Costello syndrome, LEOPARD syndrome,

Noonan-like syndrome), genomic sequence analysis panel, must

include sequencing of at least 12 genes, including BRAF, CBL, HRAS,

KRAS, MAP2K1, MAP2K2, NRAS, PTPN11, RAF1, RIT1, SHOC2, and SOS1

PA 81443 CPT

Genetic testing for severe inherited conditions (eg, cystic fibrosis,

Ashkenazi Jewish-associated disorders [eg, Bloom syndrome, Canavan

disease, Fanconi anemia type C, mucolipidosis type VI, Gaucher

disease, Tay-Sachs disease], beta hemoglobinopathies,

phenylketonuria, galactosemia), genomic sequence analysis panel,

must include sequencing of at least 15 genes (eg, ACADM, ARSA, ASPA,

ATP7B, BCKDHA, BCKDHB, BLM, CFTR, DHCR7, FANCC, G6PC, GAA,

GALT, GBA, GBE1, HBB, HEXA, IKBKAP, MCOLN1, PAH)

PA 81445 CPT

Targeted genomic sequence analysis panel, solid organ neoplasm, DNA

analysis, and RNA analysis when performed, 5-50 genes (eg, ALK,

BRAF, CDKN2A, EGFR, ERBB2, KIT, KRAS, NRAS, MET, PDGFRA, PDGFRB,

PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy

number variants or rearrangements, if performed

PA 81448 CPT

Hereditary peripheral neuropathies (eg, Charcot-Marie-Tooth, spastic

paraplegia), genomic sequence analysis panel, must include

sequencing of at least 5 peripheral neuropathy-related genes (eg,

BSCL2, GJB1, MFN2, MPZ, REEP1, SPAST, SPG11, SPTLC1)


33




PA 81450 CPT

Targeted genomic sequence analysis panel, hematolymphoid

neoplasm or disorder, DNA analysis, and RNA analysis when

performed, 5-50 genes (eg, BRAF, CEBPA, DNMT3A, EZH2, FLT3, IDH1,

IDH2, JAK2, KRAS, KIT, MLL, NRAS, NPM1, NOTCH1), interrogation for

sequence variants, and copy number variants or rearrangements, or

isoform expression or mRNA expression levels, if performed

PA 81455 CPT

Targeted genomic sequence analysis panel, solid organ or

hematolymphoid neoplasm, DNA analysis, and RNA analysis when

performed, 51 or greater genes (eg, ALK, BRAF, CDKN2A, CEBPA,

DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MLL,

NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN,

RET), interrogation for sequence variants and copy number variants or

rearrangements, if performed

PA 81460 CPT

Whole mitochondrial genome (eg, Leigh syndrome, mitochondrial

encephalomyopathy, lactic acidosis, and stroke-like episodes [MELAS],

myoclonic epilepsy with ragged-red fibers [MERFF], neuropathy,

ataxia, and retinitis pigmentosa [NARP], Leber hereditary optic

neuropathy [LHON]), genomic sequence, must include sequence

analysis of entire mitochondrial genome with heteroplasmy detection

PA 81465 CPT

Whole mitochondrial genome large deletion analysis panel (eg, Kearns-

Sayre syndrome, chronic progressive external ophthalmoplegia),

including heteroplasmy detection, if performed

PA 81470 CPT

X-linked intellectual disability (XLID) (eg, syndromic and non-syndromic

XLID); genomic sequence analysis panel, must include sequencing of at

least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1,

IL1RAPL, KDM5C, L1CAM, MECP2, MED12, MID1, OCRL, RPS6KA3, and

SLC16A2

PA 81471 CPT

X-linked intellectual disability (XLID) (eg, syndromic and non-syndromic

XLID); duplication/deletion gene analysis, must include analysis of at

least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1,

IL1RAPL, KDM5C, L1CAM, MECP2, MED12, MID1, OCRL, RPS6KA3, and

SLC16A2

PA 81479 CPT Unlisted molecular pathology procedure


34




PA 81490 CPT

Autoimmune (rheumatoid arthritis), analysis of 12 biomarkers using

immunoassays, utilizing serum, prognostic algorithm reported as a

disease activity score

PA 81493 CPT

Coronary artery disease, mRNA, gene expression profiling by real-time

RT-PCR of 23 genes, utilizing whole peripheral blood, algorithm

reported as a risk score

PA 81504 CPT

Oncology (tissue of origin), microarray gene expression profiling of >

2000 genes, utilizing formalin-fixed paraffin-embedded tissue,

algorithm reported as tissue similarity scores

PA 81507 CPT

Fetal aneuploidy (trisomy 21, 18, and 13) DNA sequence analysis of

selected regions using maternal plasma, algorithm reported as a risk

score for each trisomy

PA 81518 CPT

Oncology (breast), mRNA, gene expression profiling by real-time RT-

PCR of 11 genes (7 content and 4 housekeeping), utilizing formalin-

fixed paraffin-embedded tissue, algorithms reported as percentage

risk for metastatic recurrence and likelihood of benefit from extended

endocrine therapy

PA 81519 CPT

Oncology (breast), mRNA, gene expression profiling by real-time RT-

PCR of 21 genes, util izing formalin-fixed paraffin embedded tissue,

algorithm reported as recurrence score

PA 81520 CPT

Oncology (breast), mRNA gene expression profiling by hybrid capture

of 58 genes (50 content and 8 housekeeping), utilizing formalin-fixed

paraffin-embedded tissue, algorithm reported as a recurrence risk

score

PA 81521 CPT

Oncology (breast), mRNA, microarray gene expression profiling of 70

content genes and 465 housekeeping genes, utilizing fresh frozen or

formalin-fixed paraffin-embedded tissue, algorithm reported as index

related to risk of distant metastasis

PA 81522 CPT

Oncology (breast), mRNA, gene expression profiling by RT-PCR of 12

genes (8 content and 4 housekeeping), utilizing formalin-fixed paraffin-

embedded tissue, algorithm reported as recurrence risk score


35




PA 81525 CPT

Oncology (colon), mRNA, gene expression profiling by real-time RT-PCR

of 12 genes (7 content and 5 housekeeping), utilizing formalin-fixed

paraffin-embedded tissue, algorithm reported as a recurrence score

PA 81535 CPT

Oncology (gynecologic), l ive tumor cell culture and chemotherapeutic

response by DAPI stain and morphology, predictive algorithm reported

as a drug response score; first single drug or drug combination

PA 81536 CPT

Oncology (gynecologic), l ive tumor cell culture and chemotherapeutic

response by DAPI stain and morphology, predictive algorithm reported

as a drug response score; each additional single drug or drug

combination (List separately in addition to code for primary

procedure)

PA 81538 CPT

Oncology (lung), mass spectrometric 8-protein signature, including

amyloid A, utilizing serum, prognostic and predictive algorithm

reported as good versus poor overall survival

PA 81540 CPT

Oncology (tumor of unknown origin), mRNA, gene expression profiling

by real-time RT-PCR of 92 genes (87 content and 5 housekeeping) to

classify tumor into main cancer type and subtype, utilizing formalin-

fixed paraffin-embedded tissue, algorithm reported as a probability of

a predicted main cancer type and subtype

PA 81541 CPT

Oncology (prostate), mRNA gene expression profiling by real-time RT-

PCR of 46 genes (31 content and 15 housekeeping), utilizing formalin-

fixed paraffin-embedded tissue, algorithm reported as a disease-

specific mortality risk score

PA 81542 CPT

Oncology (prostate), mRNA, microarray gene expression profiling of 22

content genes, util izing formalin-fixed paraffin-embedded tissue,

algorithm reported as metastasis risk score

PA 81545 CPT

Oncology (thyroid), gene expression analysis of 142 genes, utilizing fine

needle aspirate, algorithm reported as a categorical result (eg, benign

or suspicious)

PA 81551 CPT

Oncology (prostate), promoter methylation profiling by real-time PCR

of 3 genes (GSTP1, APC, RASSF1), utilizing formalin-fixed paraffin-

embedded tissue, algorithm reported as a l ikelihood of prostate cancer

detection on repeat biopsy


36




PA 81595 CPT

Cardiology (heart transplant), mRNA, gene expression profiling by real-

time quantitative PCR of 20 genes (11 content and 9 housekeeping),

util izing subfraction of peripheral blood, algorithm reported as a

rejection risk score

PA 81596 CPT

Infectious disease, chronic hepatitis C virus (HCV) infection, six

biochemical assays (ALT, A2-macroglobulin, apolipoprotein A-1, total

bil irubin, GGT, and haptoglobin) utilizing serum, prognostic algorithm

reported as scores for fibrosis and necroinflammatory activity in liver

PA 83950 CPT Oncoprotein; HER-2/neu

PA 83951 CPT Oncoprotein; des-gamma-carboxy-prothrombin (DCP)

PA 84145 CPT Procalcitonin (PCT)

PA 86305 CPT Human epididymis protein 4 (HE4)

PA 90378 CPT Respiratory syncytial virus, monoclonal antibody, recombinant, for

intramuscular use, 50 mg, each

PA 90867 CPT

Therapeutic repetitive transcranial magnetic stimulation (TMS)

treatment; initial, including cortical mapping, motor threshold

determination, delivery and management

PA 90868 CPT Therapeutic repetitive transcranial magnetic stimulation (TMS)

treatment; subsequent delivery and management, per session

PA 90869 CPT

Therapeutic repetitive transcranial magnetic stimulation (TMS)

treatment; subsequent motor threshold re-determination with

delivery and management

PA 90912 CPT

Biofeedback training, perineal muscles, anorectal or urethral sphincter,

including EMG and/or manometry, when performed; initial 15 minutes

of one-on-one physician or other qualified health care professional

contact with the patient

PA 90913 CPT

Biofeedback training, perineal muscles, anorectal or urethral sphincter,

including EMG and/or manometry, when performed; each additional

15 minutes of one-on-one physician or other qualified health care

professional contact with the patient (List separatel y in addition to

code for primary procedure)


37




PA 91200 CPT Liver elastography, mechanically induced shear wave (eg, vibration),

without imaging, with interpretation and report

PA 97151 CPT

Behavior identification assessment, administered by a physician or

other qualified health care professional, each 15 minutes of the

physician's or other qualified health care professional's time face-to-

face with patient and/or guardian(s)/caregiver(s) administering

assessments and discussing findings and recommendations, and non-

face-to-face analyzing past data, scoring/interpreting the assessment,

and preparing the report/treatment plan

PA 97152 CPT

Behavior identification-supporting assessment, administered by one

technician under the direction of a physician or other qualified health

care professional, face-to-face with the patient, each 15 minutes

PA 97153 CPT

Adaptive behavior treatment by protocol, administered by technician

under the direction of a physician or other qualified health care

professional, face-to-face with one patient, each 15 minutes

PA 97154 CPT

Group adaptive behavior treatment by protocol, administered by

technician under the direction of a physician or other qualified health

care professional, face-to-face with two or more patients, each 15

minutes

PA 97155 CPT

Adaptive behavior treatment with protocol modification, administered

by physician or other qualified health care professional, which may

include simultaneous direction of technician, face-to-face with one

patient, each 15 minutes

PA 97156 CPT

Family adaptive behavior treatment guidance, administered by

physician or other qualified health care professional (with or without

the patient present), face-to-face with guardian(s)/caregiver(s), each

15 minutes

PA 97157 CPT

Multiple-family group adaptive behavior treatment guidance,

administered by physician or other qualified health care professional

(without the patient present), face-to-face with multiple sets of

guardians/caregivers, each 15 minutes

PA 97158 CPT

Group adaptive behavior treatment with protocol modification,

administered by physician or other qualified health care professional,

face-to-face with multiple patients, each 15 minutes


38




PA 0095T Category III Code

Removal of total disc arthroplasty (artificial disc), anterior approach,

each additional interspace, cervical (List separately in addition to code

for primary procedure)


Revision including replacement of total disc arthroplasty (artificial

disc), anterior approach, each additional interspace, cervical (List


PA 0111U CPT

Oncology (colon cancer), targeted KRAS (codons 12, 13, and 61) and

NRAS (codons 12, 13, and 61) gene analysis, utilizing formalin-fixed

paraffin-embedded tissue

PA 0037U CPT

Targeted genomic sequence analysis, solid organ neoplasm, DNA

analysis of 324 genes, interrogation for sequence variants, gene copy

number amplifications, gene rearrangements, microsatellite instability

and tumor mutational burden

PA 0143U CPT

Drug assay, definitive, 120 or more drugs or metabolites, urine,

quantitative liquid chromatography with tandem mass spectrometry

(LC-MS/MS) using multiple reaction monitoring (MRM), with drug or

metabolite description, comments including sample validation, per

date of service

PA 0144U CPT





date of service

PA 0145U CPT





date of service

PA 0146U CPT

Drug assay, definitive, 80 or more drugs or metabolites, urine, by




date of service


39




PA 0147U CPT





date of service

PA 0148U CPT





date of service

PA 0149U CPT





date of service

PA 0150U CPT





date of service

PA 0152U CPT

Infectious disease (bacteria, fungi, parasites, and DNA viruses), DNA,

PCR and next-generation sequencing, plasma, detection of >1,000

potential microbial organisms for significant positive pathogens

PA 0153U CPT

Oncology (breast), mRNA, gene expression profiling by next-generation

sequencing of 101 genes, utilizing formalin-fixed paraffin-embedded

tissue, algorithm reported as a triple negative breast cancer clinical

subtype(s) with information on immune cell involvement

PA 0154U CPT

FGFR3 (fibroblast growth factor receptor 3) gene analysis (ie, p.R248C

[c.742C>T], p.S249C [c.746C>G], p.G370C [c.1108G>T], p.Y373C

[c.1118A>G], FGFR3-TACC3v1, and FGFR3-TACC3v3)

PA 0155U CPT

PIK3CA (phosphatidylinositol-4,5-bisphosphate 3-kinase, catalytic

subunit alpha) (eg, breast cancer) gene analysis (ie, p.C420R, p.E542K,

p.E545A, p.E545D [g.1635G>T only], p.E545G, p.E545K, p.Q546E,

p.Q546R, p.H1047L, p.H1047R, p.H1047Y)


40




PA 0156U CPT Copy number (eg, intellectual disability, dysmorphology), sequence

analysis

PA 0157U CPT

APC (APC regulator of WNT signaling pathway) (eg, familial

adenomatosis polyposis [FAP]) mRNA sequence analysis (List


PA 0158U CPT

MLH1 (mutL homolog 1) (eg, hereditary non-polyposis colorectal

cancer, Lynch syndrome) mRNA sequence analysis (List separately in

addition to code for primary procedure)

PA 0159U CPT

MSH2 (mutS homolog 2) (eg, hereditary colon cancer, Lynch

syndrome) mRNA sequence analysis (List separately in addition to code


PA 0160U CPT

MSH6 (mutS homolog 6) (eg, hereditary colon cancer, Lynch

syndrome) mRNA sequence analysis (List separately in addition to code


PA 0161U CPT

PMS2 (PMS1 homolog 2, mismatch repair system component) (eg,

hereditary non-polyposis colorectal cancer, Lynch syndrome) mRNA

sequence analysis (List separately in addition to code for primary

procedure)

PA 0162U CPT

Hereditary colon cancer (Lynch syndrome), targeted mRNA sequence

analysis panel (MLH1, MSH2, MSH6, PMS2) (List separately in addition

to code for primary procedure)


Removal of total disc arthroplasty, (artificial disc), anterior approach,

each additional interspace, lumbar (List separately in addition to code



Revision including replacement of total disc arthroplasty (artificial

disc), anterior approach, each additional interspace, lumbar (List


PA 0169U CPT

NUDT15 (nudix hydrolase 15) and TPMT (thiopurine S-

methyltransferase) (eg, drug metabolism) gene analysis, common

variants

PA 0171U CPT Targeted genomic sequence analysis panel, acute myeloid leukemia,

myelodysplastic syndrome, and myeloproliferative neoplasms, DNA

analysis, 23 genes, interrogation for sequence variants,


41




rearrangements and minimal residual disease, reported as

presence/absence

PA 0172U CPT

Oncology (solid tumor as indicated by the label), somatic mutation

analysis of BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA

repair associated) and analysis of homologous recombination

deficiency pathways, DNA, formalin-fixed paraffin-embedded tissue,

algorithm quantifying tumor genomic instability score

PA 0173U CPT Psychiatry (ie, depression, anxiety), genomic analysis panel, includes

variant analysis of 14 genes

PA 0175U CPT Psychiatry (eg, depression, anxiety), genomic analysis panel, variant

analysis of 15 genes

PA 0178U CPT

Peanut allergen-specific quantitative assessment of multiple epitopes

using enzyme-linked immunosorbent assay (ELISA), blood, report of

minimum eliciting exposure for a clinical reaction


Exposure behavioral follow-up assessment, includes physician or other

qualified health care professional direction with interpretation and

report, administered by physician or other qualified health care

professional with the assistance of one or more technicians; first 30

minutes of technician(s) time, face-to-face with the patient


Exposure adaptive behavior treatment with protocol modification

requiring two or more technicians for severe maladaptive behavior(s);

first 60 minutes of technicians' time, face-to-face with patient

PA 0402T Category III Code Collagen cross-linking of cornea (including removal of the corneal

epithelium and intraoperative pachymetry when performed)


Chimeric antigen receptor T-cell (CAR-T) therapy; harvesting of blood-

derived T lymphocytes for development of genetically modified

autologous CAR-T cells, per day


Chimeric antigen receptor T-cell (CAR-T) therapy; preparation of blood-

derived T lymphocytes for transportation (eg, cryopreservation,

storage)


42




PA 0539T Category III Code Chimeric antigen receptor T-cell (CAR-T) therapy; receipt and

preparation of CAR-T cells for administration

PA 0540T Category III Code Chimeric antigen receptor T-cell (CAR-T) therapy; CAR-T cell

administration, autologous

PA A7007 HCPCS Large volume nebulizer, disposable, unfilled, used with aerosol

compressor

PA A7008 HCPCS Large volume nebulizer, disposable, prefilled, used with aerosol

compressor

PA A7025 HCPCS High frequency chest wall oscillation system vest, replacement for use

with patient-owned equipment, each

PA A7026 HCPCS High frequency chest wall oscillation system hose, replacement for use

with patient-owned equipment, each

PA A9277 HCPCS Transmitter; External, for use with interstitial continous glucose

monitoring system

PA A9278 HCPCS Receiver (monitor); external, for use with interstitial continuous

glucose monitoring system

PA B4149 HCPCS

Enteral formula, manufactured blenderized natural foods with intact

nutrients, includes proteins, fats, carbohydrates, vitamins and

minerals, may include fiber, administered through an enteral feeding

tube, 100 calories = 1 unit

PA B4150 HCPCS

Enteral formula, nutritionally complete with intact nutrients, includes

proteins, fats, carbohydrates, vitamins and minerals, may include fiber,

administered through an enteral feeding tube, 100 calories = 1 unit

PA B4152 HCPCS

Enteral formula, nutritionally complete, calorically dense (equal to or

greater than 1.5 kcal/ml) with intact nutrients, includes proteins, fats,

carbohydrates, vitamins and minerals, may include fiber, administered

through an enteral feeding tube, 100 calories = 1 unit

PA B4153 HCPCS

Enteral formula, nutritionally complete, hydrolyzed proteins (amino

acids and peptide chain), includes fats, carbohydrates, vitamins and




43




PA B4154 HCPCS

Enteral formula, nutritionally complete, for special metabolic needs,

excludes inherited disease of metabolism, includes altered

composition of proteins, fats, carbohydrates, vitamins and/or



PA B4155 HCPCS

Enteral formula, nutritionally incomplete/modular nutrients, includes

specific nutrients, carbohydrates (e.g., glucose polymers),

proteins/amino acids (e.g., glutamine, arginine), fat (e.g., medium

chain triglycerides) or combination, administered through an enteral

feeding tube, 100 calories = 1 unit

PA B4157 HCPCS

Enteral formula, nutritionally complete, for special metabolic needs for

inherited disease of metabolism, includes proteins, fats,

carbohydrates, vitamins and minerals, may include fiber, administered

through an enteral feeding tube, 100 calories = 1 unit

PA B4158 HCPCS

Enteral formula, for pediatrics, nutritionally complete with intact

nutrients, includes proteins, fats, carbohydrates, vitamins and

minerals, may include fiber and/or iron, administered through an

enteral feeding tube, 100 calories = 1 unit

PA B4159 HCPCS

Enteral formula, for pediatrics, nutritionally complete soy based with

intact nutrients, includes proteins, fats, carbohydrates, vitamins and

minerals, may include fiber and/or iron, administered through an

enteral feeding tube, 100 calories = 1 unit

PA B4160 HCPCS

Enteral formula, for pediatrics, nutritionally complete calorically dense

(equal to or greater than 0.7 kcal/ml) with intact nutrients, includes

proteins, fats, carbohydrates, vitamins and minerals, may include fiber,

administered through an enteral feeding tube, 100 calories = 1 unit

PA B4161 HCPCS

Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide

chain proteins, includes fats, carbohydrates, vitamins and minerals,

may include fiber, administered through an enteral feeding tube, 100

calories = 1 unit


44




PA B4162 HCPCS

Enteral formula, for pediatrics, special metabolic needs for inherited

disease of metabolism, includes proteins, fats, carbohydrates, vitamins

and minerals, may include fiber, administered through an enteral

feeding tube, 100 calories = 1 unit

PA B4164 HCPCS Parenteral nutrition solution: carbohydrates (dextrose), 50% or less

(500 ml = 1 unit), home mix

PA B4168 HCPCS Parenteral nutrition solution; amino acid, 3.5%, (500 ml = 1 unit) -

home mix

PA B4172 HCPCS Parenteral nutrition solution; amino acid, 5.5% through 7%, (500 ml = 1

unit) - home mix

PA B4176 HCPCS Parenteral nutrition solution; amino acid, 7% through 8.5%, (500 ml = 1

unit) - home mix

PA B4178 HCPCS Parenteral nutrition solution: amino acid, greater than 8.5% (500 ml =

1 unit), home mix

PA B4180 HCPCS Parenteral nutrition solution: carbohydrates (dextrose), greater than

50% (500 ml = 1 unit), home mix

PA B4185 HCPCS Parenteral nutrition solution, per 10 grams lipids

PA B4187 HCPCS Omegaven, 10 g l ipids

PA B4189 HCPCS

Parenteral nutrition solution: compounded amino acid and

carbohydrates with electrolytes, trace elements, and vitamins,

including preparation, any strength, 10 to 51 g of protein, premix

PA B4193 HCPCS

Parenteral nutrition solution: compounded amino acid and


including preparation, any strength, 52 to 73 g of protein, premix

PA B4216 HCPCS Parenteral nutrition; additives (vitamins, trace elements, Heparin,

electrolytes), home mix, per day

PA B5100 HCPCS

Parenteral nutrition solution compounded amino acid and


including preparation, any strength, hepatic-HepatAmine-premix

PA C9122 HCPCS Mometasone furoate sinus implant, 10 mcg (Sinuva)


45




PA C9756 HCPCS

Intraoperative near-infrared fluorescence lymphatic mapping of lymph

node(s) (sentinel or tumor draining) with administration of

indocyanine green (ICG) (List separately in addition to code for primary

procedure)

PA D0423 HCPCS genetic test for susceptibility to diseases - specimen analysis

PA D2390 HCPCS resin-based composite crown, anterior

PA D2510 HCPCS inlay - metallic - one surface

PA D2520 HCPCS inlay - metallic - two surfaces

PA D2530 HCPCS inlay - metallic - three or more surfaces

PA D2542 HCPCS onlay - metallic-two surfaces

PA D2543 HCPCS onlay - metallic-three surfaces

PA D2544 HCPCS onlay - metallic-four or more surfaces

PA D2610 HCPCS inlay - porcelain/ceramic - one surface

PA D2620 HCPCS inlay - porcelain/ceramic - two surfaces

PA D2630 HCPCS inlay - porcelain/ceramic - three or more surfaces

PA D2642 HCPCS onlay - porcelain/ceramic - two surfaces

PA D2643 HCPCS onlay - porcelain/ceramic - three surfaces

PA D2644 HCPCS onlay - porcelain/ceramic - four or more surfaces

PA D2650 HCPCS inlay - resin-based composite - one surface

PA D2651 HCPCS inlay - resin-based composite - two surfaces

PA D2652 HCPCS inlay - resin-based composite - three or more surfaces

PA D2662 HCPCS onlay - resin-based composite - two surfaces

PA D2663 HCPCS onlay - resin-based composite - three surfaces

PA D2664 HCPCS onlay - resin-based composite - four or more surfaces

PA D2710 HCPCS crown - resin-based composite (indirect)

PA D2712 HCPCS crown - 3/4 resin-based composite (indirect)


46




PA D2720 HCPCS crown - resin with high noble metal

PA D2721 HCPCS crown - resin with predominantly base metal

PA D2722 HCPCS crown - resin with noble metal

PA D2740 HCPCS crown - porcelain/ceramic substrate

PA D2750 HCPCS crown - porcelain fused to high noble metal

PA D2751 HCPCS crown - porcelain fused to predominantly base metal

PA D2752 HCPCS crown - porcelain fused to noble metal

PA D2780 HCPCS crown - 3/4 cast high noble metal

PA D2781 HCPCS crown - 3/4 cast predominantly base metal

PA D2782 HCPCS crown - 3/4 cast noble metal

PA D2783 HCPCS crown - 3/4 porcelain/ceramic

PA D2790 HCPCS crown - full cast high noble metal

PA D2791 HCPCS crown - full cast predominantly base metal

PA D2792 HCPCS crown - full cast noble metal

PA D2794 HCPCS crown - titanium

PA D2929 HCPCS prefabricated porcelain/ceramic crown - primary tooth

PA D2930 HCPCS prefabricated stainless steel crown - primary tooth

PA D2931 HCPCS prefabricated stainless steel crown - permanent tooth

PA D2932 HCPCS prefabricated resin crown

PA D2933 HCPCS prefabricated stainless steel crown with resin window

PA D2934 HCPCS prefabricated esthetic coated stainless steel crown - primary tooth

PA D6058 HCPCS abutment supported porcelain/ceramic crown

PA D6059 HCPCS abutment supported porcelain fused to metal crown (high noble

metal)


47




PA D6060 HCPCS abutment supported porcelain fused to metal crown (predominantly

base metal)

PA D6061 HCPCS abutment supported porcelain fused to metal crown (noble metal)

PA D6062 HCPCS abutment supported cast metal crown (high noble metal)

PA D6063 HCPCS abutment supported cast metal crown (predominantly base metal)

PA D6064 HCPCS abutment supported cast metal crown (noble metal)

PA D6065 HCPCS implant supported porcelain/ceramic crown

PA D6066 HCPCS implant supported porcelain fused to metal crown (titanium, titanium

alloy, high noble metal)

PA D6067 HCPCS implant supported metal crown (titanium, titanium alloy, high noble

metal)

PA D6068 HCPCS abutment supported retainer for porcelain/ceramic FPD

PA D6069 HCPCS abutment supported retainer for porcelain fused to metal FPD (high

noble metal)

PA D6070 HCPCS abutment supported retainer for porcelain fused to metal FPD

(predominantly base metal)

PA D6071 HCPCS abutment supported retainer for porcelain fused to metal FPD (noble

metal)

PA D6072 HCPCS abutment supported retainer for cast metal FPD (high noble metal)

PA D6073 HCPCS abutment supported retainer for cast metal FPD (predominantly base

metal)

PA D6074 HCPCS abutment supported retainer for cast metal FPD (noble metal)

PA D6075 HCPCS implant supported retainer for ceramic FPD

PA D6076 HCPCS implant supported retainer for porcelain fused to metal FPD (titanium,

titanium alloy, or high noble metal)

PA D6077 HCPCS implant supported retainer for cast metal FPD (titanium, titanium

alloy, or high noble metal)


48




PA D6085 HCPCS provisional implant crown

PA D6194 HCPCS abutment supported retainer crown for FPD (titanium)

PA D6205 HCPCS pontic - indirect resin based composite

PA D6210 HCPCS pontic - cast high noble metal

PA D6211 HCPCS pontic - cast predominantly base metal

PA D6212 HCPCS pontic - cast noble metal

PA D6214 HCPCS pontic - titanium

PA D6240 HCPCS pontic - porcelain fused to high noble metal

PA D6241 HCPCS pontic - porcelain fused to predominantly base metal

PA D6242 HCPCS pontic - porcelain fused to noble metal

PA D6245 HCPCS pontic - porcelain/ceramic

PA D6250 HCPCS pontic - resin with high noble metal

PA D6251 HCPCS pontic - resin with predominantly base metal

PA D6252 HCPCS pontic - resin with noble metal

PA D6545 HCPCS retainer - cast metal for resin bonded fixed prosthesis

PA D6548 HCPCS retainer - porcelain/ceramic for resin bonded fixed prosthesis

PA D6600 HCPCS retainer inlay - porcelain/ceramic, two surfaces

PA D6601 HCPCS retainer inlay - porcelain/ceramic, three or more surfaces

PA D6602 HCPCS retainer inlay - cast high noble metal, two surfaces

PA D6603 HCPCS retainer inlay - cast high noble metal, three or more surfaces

PA D6604 HCPCS retainer inlay - cast predominantly base metal, two surfaces

PA D6605 HCPCS retainer inlay - cast predominantly base metal, three or more surfaces

PA D6606 HCPCS retainer inlay - cast noble metal, two surfaces

PA D6607 HCPCS retainer inlay - cast noble metal, three or more surfaces


49




PA D6608 HCPCS retainer onlay - porcelain/ceramic, two surfaces

PA D6609 HCPCS retainer onlay - porcelain/ceramic, three or more surfaces

PA D6610 HCPCS retainer onlay - cast high noble metal, two surfaces

PA D6611 HCPCS retainer onlay - cast high noble metal, three or more surfaces

PA D6612 HCPCS retainer onlay - cast predominantly base metal, two surfaces

PA D6613 HCPCS retainer onlay - cast predominantly base metal, three or more surfaces

PA D6614 HCPCS retainer onlay - cast noble metal, two surfaces

PA D6615 HCPCS retainer onlay - cast noble metal, three or more surfaces

PA D6624 HCPCS retainer inlay - titanium

PA D6634 HCPCS retainer onlay - titanium

PA D6710 HCPCS retainer crown - indirect resin based composite

PA D6720 HCPCS retainer crown - resin with high noble metal

PA D6721 HCPCS retainer crown - resin with predominantly base metal

PA D6722 HCPCS retainer crown - resin with noble metal

PA D6740 HCPCS retainer crown - porcelain/ceramic

PA D6750 HCPCS retainer crown - porcelain fused to high noble metal

PA D6751 HCPCS retainer crown - porcelain fused to predominantly base metal

PA D6752 HCPCS retainer crown - porcelain fused to noble metal

PA D6780 HCPCS retainer crown - 3/4 cast high noble metal

PA D6781 HCPCS retainer crown - 3/4 cast predominantly base metal

PA D6782 HCPCS retainer crown - 3/4 cast noble metal

PA D6783 HCPCS retainer crown - 3/4 porcelain/ceramic

PA D6790 HCPCS retainer crown - full cast high noble metal

PA D6791 HCPCS retainer crown - full cast predominantly base metal


50




PA D6792 HCPCS retainer crown - full cast noble metal

PA D6794 HCPCS retainer crown - titanium

PA D8010 HCPCS limited orthodontic treatment of the primary dentition

PA D8020 HCPCS limited orthodontic treatment of the transitional dentition

PA D8030 HCPCS limited orthodontic treatment of the adolescent dentition

PA D8050 HCPCS interceptive orthodontic treatment of the primary dentition

PA D8060 HCPCS interceptive orthodontic treatment of the transitional dentition

PA D8070 HCPCS comprehensive orthodontic treatment of the transitional dentition

PA D8080 HCPCS comprehensive orthodontic treatment of the adolescent dentition

PA D8210 HCPCS removable appliance therapy

PA D8220 HCPCS fixed appliance therapy

PA D8660 HCPCS pre-orthodontic treatment examination to monitor growth and

development

PA D8670 HCPCS periodic orthodontic treatment visit

PA D8680 HCPCS orthodontic retention (removal of appliances, construction and

placement of retainer(s))

PA D8681 HCPCS removable orthodontic retainer adjustment

PA D8690 HCPCS orthodontic treatment (alternative billing to a contract fee)

PA E0193 HCPCS Powered air flotation bed (low air loss therapy)

PA E0194 HCPCS Air fluidized bed

PA E0250 HCPCS Hospital bed, fixed height, with any type side rails, with mattress

PA E0251 HCPCS Hospital bed, fixed height, with any type side rails, without mattress

PA E0255 HCPCS Hospital bed, variable height, hi -lo, with any type side rails, with

mattress


51




PA E0256 HCPCS Hospital bed, variable height, hi -lo, with any type side rails, without

mattress

PA E0260 HCPCS Hospital bed, semi-electric (head and foot adjustment), with any type

side rails, with mattress

PA E0261 HCPCS Hospital bed, semi-electric (head and foot adjustment), with any type

side rails, without mattress

PA E0265 HCPCS Hospital bed, total electric (head, foot, and height adjustments), with

any type side rails, with mattress

PA E0266 HCPCS Hospital bed, total electric (head, foot, and height adjustments), with

any type side rails, without mattress

PA E0270 HCPCS Hospital bed, institutional type includes: oscillating, circulating and

Stryker frame, with mattress

PA E0277 HCPCS Powered pressure-reducing air mattress

PA E0290 HCPCS Hospital bed, fixed height, without side rails, with mattress

PA E0291 HCPCS Hospital bed, fixed height, without side rails, without mattress

PA E0292 HCPCS Hospital bed, variable height, hi -lo, without side rails, with mattress

PA E0293 HCPCS Hospital bed, variable height, hi -lo, without side rails, without mattress

PA E0294 HCPCS Hospital bed, semi-electric (head and foot adjustment), without side

rails, with mattress

PA E0295 HCPCS Hospital bed, semi-electric (head and foot adjustment), without side

rails, without mattress

PA E0296 HCPCS Hospital bed, total electric (head, foot, and height adjustments),

without side rails, with mattress

PA E0297 HCPCS Hospital bed, total electric (head, foot, and height adjustments),

without side rails, without mattress

PA E0300 HCPCS Pediatric crib, hospital grade, fully enclosed, with or without top

enclosure


52




PA E0301 HCPCS

Hospital bed, heavy-duty, extra wide, with weight capacity greater

than 350 pounds, but less than or equal to 600 pounds, with any type

side rails, without mattress

PA E0302 HCPCS Hospital bed, extra heavy-duty, extra wide, with weight capacity

greater than 600 pounds, with any type side rails, without mattress

PA E0303 HCPCS

Hospital bed, heavy-duty, extra wide, with weight capacity greater

than 350 pounds, but less than or equal to 600 pounds, with any type

side rails, with mattress

PA E0304 HCPCS Hospital bed, extra heavy-duty, extra wide, with weight capacity

greater than 600 pounds, with any type side rails, with mattress

PA E0328 HCPCS

Hospital bed, pediatric, manual, 360 degree side enclosures, top of

headboard, footboard and side rails up to 24 in above the spring,

includes mattress

PA E0329 HCPCS

Hospital bed, pediatric, electric or semi-electric, 360 degree side

enclosures, top of headboard, footboard and side rails up to 24 in

above the spring, includes mattress

PA E0350 HCPCS Control unit for electronic bowel irrigation/evacuation system

PA E0352 HCPCS

Disposable pack (water reservoir bag, speculum, valving mechanism,

and collection bag/box) for use with the electronic bowel

irrigation/evacuation system

PA E0370 HCPCS Air pressure elevator for heel

PA E0371 HCPCS Nonpowered advanced pressure reducing overlay for mattress,

standard mattress length and width

PA E0372 HCPCS Powered air overlay for mattress, standard mattress length and width

PA E0373 HCPCS Nonpowered advanced pressure reducing mattress

PA E0457 HCPCS Chest shell (cuirass)

PA E0459 HCPCS Chest wrap

PA E0462 HCPCS Rocking bed, with or without side rails

PA E0480 HCPCS Percussor, electric or pneumatic, home model


53




PA E0482 HCPCS Cough stimulating device, alternating positive and negative airway

pressure

PA E0483 HCPCS High Frequency Chest Compression Device – Airway Clearance Vests

PA E0484 HCPCS Oscillatory positive expiratory pressure device, nonelectric, any type,

each

PA E0485 HCPCS

Oral device/appliance used to reduce upper airway collapsibility,

adjustable or nonadjustable, prefabricated, includes fitting and

adjustment

PA E0565 HCPCS Compressor, air power source for equipment which is not self-

contained or cylinder driven

PA E0575 HCPCS Nebulizer, ultrasonic, large volume

PA E0636 HCPCS Multipositional patient support system, with integrated lift, patient

accessible controls

PA E0650 HCPCS Pneumatic compressor, nonsegmental home model

PA E0651 HCPCS Pneumatic compressor, segmental home model without calibrated

gradient pressure

PA E0652 HCPCS Pneumatic compressor, segmental home model with calibrated

gradient pressure

PA E0691 HCPCS Ultraviolet l ight therapy system, includes bulbs/lamps, timer and eye

protection; treatment area 2 sq ft or less

PA E0692 HCPCS Ultraviolet l ight therapy system panel, includes bulbs/lamps, timer and

eye protection, 4 ft panel

PA E0693 HCPCS Ultraviolet l ight therapy system panel, includes bulbs/lamps, timer and

eye protection, 6 ft panel

PA E0694 HCPCS Ultraviolet multidirectional l ight therapy system in 6 ft cabinet,

includes bulbs/lamps, timer, and eye protection

PA E0720 HCPCS Transcutaneous electrical nerve stimulation (TENS) device, 2 lead,

localized stimulation

PA E0730 HCPCS Transcutaneous electrical nerve stimulation (TENS) device, 4 or more

leads, for multiple nerve stimulation


54




PA E0731 HCPCS Form-fitting conductive garment for delivery of TENS or NMES (with

conductive fibers separated from the patient's skin by layers of fabric)

PA E0745 HCPCS Neuromuscular stimulator, electronic shock unit

PA E0747 HCPCS Osteogenesis stimulator, electrical, noninvasive, other than spinal

applications

PA E0748 HCPCS Osteogenesis stimulator, electrical, noninvasive, spinal applications

PA E0749 HCPCS Osteogenesis stimulator, electrical, surgically implanted

PA E0760 HCPCS Osteogenesis stimulator, low intensity ultrasound, noninvasive

PA E0762 HCPCS Transcutaneous electrical joint stimulation device system, includes all

accessories

PA E0764 HCPCS

Functional neuromuscular stimulation, transcutaneous stimulation of

sequential muscle groups of ambulation with computer control, used

for walking by spinal cord injured, entire system, after completion of

training program

PA E0766 HCPCS Electrical stimulation device used for cancer treatment, includes all

accessories, any type

PA E0770 HCPCS

Functional electrical stimulator, transcutaneous stimulation of nerve

and/or muscle groups, any type, complete system, not otherwise

specified

PA E0782 HCPCS Infusion pump, implantable, nonprogrammable (includes all

components, e.g., pump, catheter, connectors, etc.)

PA E0783 HCPCS Infusion pump system, implantable, programmable (includes all

components, e.g., pump, catheter, connectors, etc.)

PA E0785 HCPCS Implantable intraspinal (epidural/intrathecal) catheter used with

implantable infusion pump, replacement

PA E0786 HCPCS Implantable programmable infusion pump, replacement (excludes

implantable intraspinal catheter)

PA E0935 HCPCS Continuous passive motion exercise device for use on knee only

PA E0936 HCPCS Continuous passive motion exercise device for use other than knee


55




PA E1035 HCPCS

Multi-positional patient transfer system, with integrated seat,

operated by care giver, patient weight capacity up to and including 300

lbs

PA E1036 HCPCS

Multi-positional patient transfer system, extra-wide, with integrated

seat, operated by caregiver, patient weight capacity greater than 300

lbs

PA E1050 HCPCS Fully-reclining wheelchair, fixed full-length arms, swing-away

detachable elevating legrests

PA E1060 HCPCS Fully-reclining wheelchair, detachable arms, desk or full-length, swing-

away detachable elevating legrests

PA E1070 HCPCS Fully-reclining wheelchair, detachable arms (desk or full-length) swing-

away detachable footrest

PA E1083 HCPCS Hemi-wheelchair, fixed full-length arms, swing-away detachable

elevating legrest

PA E1084 HCPCS Hemi-wheelchair, detachable arms desk or full-length arms, swing-


PA E1085 HCPCS Hemi-wheelchair, fixed full-length arms, swing-away detachable

footrests

PA E1086 HCPCS Hemi-wheelchair, detachable arms, desk or full-length, swing-away

detachable footrests

PA E1087 HCPCS High strength lightweight wheelchair, fixed full-length arms, swing-


PA E1088 HCPCS High strength lightweight wheelchair, detachable arms desk or full-

length, swing-away detachable elevating legrests

PA E1089 HCPCS High-strength lightweight wheelchair, fixed-length arms, swing-away

detachable footrest

PA E1090 HCPCS High-strength lightweight wheelchair, detachable arms, desk or full-

length, swing-away detachable footrests

PA E1092 HCPCS Wide heavy-duty wheelchair, detachable arms (desk or full-length),

swing-away detachable elevating legrests

PA E1093 HCPCS Wide heavy-duty wheelchair, detachable arms, desk or full-length

arms, swing-away detachable footrests


56




PA E1100 HCPCS Semi-reclining wheelchair, fixed full-length arms, swing-away


PA E1110 HCPCS Semi-reclining wheelchair, detachable arms (desk or full-length)

elevating legrest

PA E1130 HCPCS Standard wheelchair, fixed full-length arms, fixed or swing-away


PA E1140 HCPCS Wheelchair, detachable arms, desk or full-length, swing-away


PA E1150 HCPCS Wheelchair, detachable arms, desk or full-length swing-away


PA E1160 HCPCS Wheelchair, fixed full-length arms, swing-away detachable elevating

legrests

PA E1161 HCPCS Manual adult size wheelchair, includes ti lt in space

PA E1170 HCPCS Amputee wheelchair, fixed full-length arms, swing-away detachable

elevating legrests

PA E1171 HCPCS Amputee wheelchair, fixed full-length arms, without footrests or

legrest

PA E1172 HCPCS Amputee wheelchair, detachable arms (desk or full-length) without

footrests or legrest

PA E1180 HCPCS Amputee wheelchair, detachable arms (desk or full-length) swing-away


PA E1190 HCPCS Amputee wheelchair, detachable arms (desk or full-length) swing-away


PA E1195 HCPCS Heavy-duty wheelchair, fixed full-length arms, swing-away detachable

elevating legrests

PA E1200 HCPCS Amputee wheelchair, fixed full-length arms, swing-away detachable

footrest

PA E1220 HCPCS Wheelchair; specially sized or constructed, (indicate brand name,

model number, if any) and justification

PA E1221 HCPCS Wheelchair with fixed arm, footrests


57




PA E1222 HCPCS Wheelchair with fixed arm, elevating legrests

PA E1223 HCPCS Wheelchair with detachable arms, footrests

PA E1224 HCPCS Wheelchair with detachable arms, elevating legrests

PA E1229 HCPCS Wheelchair, pediatric size, not otherwise specified

PA E1230 HCPCS Power operated vehicle (3- or 4-wheel nonhighway), specify brand

name and model number

PA E1231 HCPCS Wheelchair, pediatric size, ti lt-in-space, rigid, adjustable, with seating

system

PA E1232 HCPCS Wheelchair, pediatric size, ti lt-in-space, folding, adjustable, with

seating system

PA E1233 HCPCS Wheelchair, pediatric size, ti lt-in-space, rigid, adjustable, without

seating system

PA E1234 HCPCS Wheelchair, pediatric size, ti lt-in-space, folding, adjustable, without

seating system

PA E1235 HCPCS Wheelchair, pediatric size, rigid, adjustable, with seating system

PA E1236 HCPCS Wheelchair, pediatric size, folding, adjustable, with seating system

PA E1237 HCPCS Wheelchair, pediatric size, rigid, adjustable, without seating system

PA E1238 HCPCS Wheelchair, pediatric size, folding, adjustable, without seating system

PA E1239 HCPCS Power wheelchair, pediatric size, not otherwise specified

PA E1240 HCPCS Lightweight wheelchair, detachable arms, (desk or full-length) swing-

away detachable, elevating legrest

PA E1250 HCPCS Lightweight wheelchair, fixed full-length arms, swing-away detachable

footrest

PA E1260 HCPCS Lightweight wheelchair, detachable arms (desk or full-length) swing-


PA E1270 HCPCS Lightweight wheelchair, fixed full-length arms, swing-away detachable

elevating legrests


58




PA E1280 HCPCS Heavy-duty wheelchair, detachable arms (desk or full-length) elevating

legrests

PA E1285 HCPCS Heavy-duty wheelchair, fixed full-length arms, swing-away detachable

footrest

PA E1290 HCPCS Heavy-duty wheelchair, detachable arms (desk or full-length) swing-


PA E1295 HCPCS Heavy-duty wheelchair, fixed full-length arms, elevating legrest

PA E1590 HCPCS Hemodialysis machine

PA E1615 HCPCS Deionizer water purification system, for hemodialysis

PA E1625 HCPCS Water softening system, for hemodialysis

PA E2291 HCPCS Back, planar, for pediatric size wheelchair including fixed attaching

hardware

PA E2292 HCPCS Seat, planar, for pediatric size wheelchair including fixed attaching

hardware

PA E2293 HCPCS Back, contoured, for pediatric size wheelchair including fixed attaching

hardware

PA E2398 HCPCS Wheelchair accessory, dynamic positioning hardware for back

PA E2402 HCPCS Negative pressure wound therapy electrical pump, stationary or

portable

PA E2500 HCPCS Speech generating device, digitized speech, using prerecorded

messages, less than or equal to 8 minutes recording time

PA E2502 HCPCS

Speech generating device, digitized speech, using prerecorded

messages, greater than 8 minutes but less than or equal to 20 minutes

recording time

PA E2504 HCPCS

Speech generating device, digitized speech, using prerecorded

messages, greater than 20 minutes but less than or equal to 40

minutes recording time

PA E2506 HCPCS Speech generating device, digitized speech, using prerecorded

messages, greater than 40 minutes recording time


59




PA E2508 HCPCS Speech generating device, synthesized speech, requiring message

formulation by spelling and access by physical contact with the device

PA E2510 HCPCS

Speech generating device, synthesized speech, permitting multiple

methods of message formulation and multiple methods of device

access

PA E2511 HCPCS Speech generating software program, for personal computer or

personal digital assistant

PA E2512 HCPCS Accessory for speech generating device, mounting system

PA E2599 HCPCS Accessory for speech generating device, not otherwise classified

PA G0277 HCPCS Hyperbaric oxygen under pressure, full body chamber, per 30 minute

interval

PA G0283 HCPCS Electrical stimulation (unattended), to one or more areas for

indication(s) other than wound care, as part of a therapy plan of care

PA K0001 HCPCS Standard wheelchair

PA K0002 HCPCS Standard hemi (low seat) wheelchair

PA K0003 HCPCS Lightweight wheelchair

PA K0004 HCPCS High strength, lightweight wheelchair

PA K0005 HCPCS Ultralightweight wheelchair

PA K0006 HCPCS Heavy-duty wheelchair

PA K0007 HCPCS Extra heavy-duty wheelchair

PA K0008 HCPCS Custom manual wheelchair/base

PA K0009 HCPCS Other manual wheelchair/base

PA K0010 HCPCS Standard-weight frame motorized/power wheelchair

PA K0011 HCPCS

Standard-weight frame motorized/power wheelchair with

programmable control parameters for speed adjustment, tremor

dampening, acceleration control and braking

PA K0012 HCPCS Lightweight portable motorized/power wheelchair


60




PA K0013 HCPCS Custom motorized/power wheelchair base

PA K0014 HCPCS Other motorized/power wheelchair base

PA K0455 HCPCS Infusion pump used for uninterrupted parenteral administration of

medication, (e.g., epoprostenol or treprostinol)

PA K0552 HCPCS Supplies for external non-insulin drug infusion pump, syringe type

cartridge, sterile, each

PA K0554 HCPCS Receiver (monitor), dedicated, for use with therapeutic glucose

continuous monitor system

PA K0601 HCPCS Replacement battery for external infusion pump owned by patient,

si lver oxide, 1.5 volt, each


si lver oxide, 3 volt, each


alkaline, 1.5 volt, each


l ithium, 3.6 volt, each


l ithium, 4.5 volt, each

PA K0606 HCPCS Automatic external defibrillator, with integrated electrocardiogram

analysis, garment type

PA K0607 HCPCS Replacement battery for automated external defibrillator, garment

type only, each

PA K0608 HCPCS Replacement garment for use with automated external defibrillator,

each

PA K0609 HCPCS Replacement electrodes for use with automated external defibrillator,

garment type only, each

PA K0672 HCPCS Addition to lower extremity orthotic, removable soft interface, all

components, replacement only, each

PA K0730 HCPCS Controlled dose inhalation drug delivery system

PA K0743 HCPCS Suction pump, home model, portable, for use on wounds


61




PA K0744 HCPCS Absorptive wound dressing for use with suction pump, home model,

portable, pad size 16 sq in or less


portable, pad size more than 16 sq in but less than or equal to 48 sq in


portable, pad size greater than 48 sq in

PA K0800 HCPCS Power operated vehicle, group 1 standard, patient weight capacity up

to and including 300 pounds

PA K0801 HCPCS Power operated vehicle, group 1 heavy-duty, patient weight capacity

301 to 450 pounds

PA K0802 HCPCS Power operated vehicle, group 1 very heavy-duty, patient weight

capacity 451 to 600 pounds

PA K0806 HCPCS Power operated vehicle, group 2 standard, patient weight capacity up

to and including 300 pounds

PA K0807 HCPCS Power operated vehicle, group 2 heavy-duty, patient weight capacity

301 to 450 pounds

PA K0808 HCPCS Power operated vehicle, group 2 very heavy-duty, patient weight


PA K0812 HCPCS Power operated vehicle, not otherwise classified

PA K0813 HCPCS Power wheelchair, group 1 standard, portable, sling/solid seat and

back, patient weight capacity up to and including 300 pounds

PA K0814 HCPCS Power wheelchair, group 1 standard, portable, captain's chair, patient

weight capacity up to and including 300 pounds

PA K0815 HCPCS Power wheelchair, group 1 standard, sling/solid seat and back, patient


PA K0816 HCPCS Power wheelchair, group 1 standard, captain's chair, patient weight

capacity up to and including 300 pounds

PA K0820 HCPCS Power wheelchair, group 2 standard, portable, sling/solid seat/back,

patient weight capacity up to and including 300 pounds


62




PA K0821 HCPCS Power wheelchair, group 2 standard, portable, captain's chair, patient


PA K0822 HCPCS Power wheelchair, group 2 standard, sling/solid seat/back, patient




PA K0824 HCPCS Power wheelchair, group 2 heavy-duty, sling/solid seat/back, patient

weight capacity 301 to 450 pounds

PA K0825 HCPCS Power wheelchair, group 2 heavy-duty, captain's chair, patient weight


PA K0826 HCPCS Power wheelchair, group 2 very heavy-duty, sling/solid seat/back,

patient weight capacity 451 to 600 pounds

PA K0827 HCPCS Power wheelchair, group 2 very heavy-duty, captain's chair, patient


PA K0828 HCPCS Power wheelchair, group 2 extra heavy-duty, sling/solid seat/back,

patient weight capacity 601 pounds or more

PA K0829 HCPCS Power wheelchair, group 2 extra heavy-duty, captain's chair, patient

weight 601 pounds or more

PA K0830 HCPCS Power wheelchair, group 2 standard, seat elevator, sling/solid

seat/back, patient weight capacity up to and including 300 pounds

PA K0831 HCPCS Power wheelchair, group 2 standard, seat elevator, captain's chair,

patient weight capacity up to and including 300 pounds

PA K0835 HCPCS Power wheelchair, group 2 standard, single power option, sling/solid


PA K0836 HCPCS Power wheelchair, group 2 standard, single power option, captain's

chair, patient weight capacity up to and including 300 pounds

PA K0837 HCPCS Power wheelchair, group 2 heavy-duty, single power option, sling/solid

seat/back, patient weight capacity 301 to 450 pounds

PA K0838 HCPCS Power wheelchair, group 2 heavy-duty, single power option, captain's

chair, patient weight capacity 301 to 450 pounds


63




PA K0839 HCPCS Power wheelchair, group 2 very heavy-duty, single power option

sling/solid seat/back, patient weight capacity 451 to 600 pounds

PA K0840 HCPCS Power wheelchair, group 2 extra heavy-duty, single power option,

sling/solid seat/back, patient weight capacity 601 pounds or more

PA K0841 HCPCS

Power wheelchair, group 2 standard, multiple power option,

sling/solid seat/back, patient weight capacity up to and including 300

pounds

PA K0842 HCPCS Power wheelchair, group 2 standard, multiple power option, captain's


PA K0843 HCPCS Power wheelchair, group 2 heavy-duty, multiple power option,








PA K0851 HCPCS Power wheelchair, group 3 heavy-duty, captain's chair, patient weight




PA K0853 HCPCS Power wheelchair, group 3 very heavy-duty, captain's chair, patient


PA K0854 HCPCS Power wheelchair, group 3 extra heavy-duty, sling/solid seat/back,

patient weight capacity 601 pounds or more

PA K0855 HCPCS Power wheelchair, group 3 extra heavy-duty, captain's chair, patient

weight capacity 601 pounds or more




64







seat/back, patient weight 301 to 450 pounds

PA K0859 HCPCS Power wheelchair, group 3 heavy-duty, single power option, captain's

chair, patient weight capacity 301 to 450 pounds

PA K0860 HCPCS Power wheelchair, group 3 very heavy-duty, single power option,


PA K0861 HCPCS



pounds



PA K0863 HCPCS Power wheelchair, group 3 very heavy-duty, multiple power option,


PA K0864 HCPCS Power wheelchair, group 3 extra heavy-duty, multiple power option,

sling/solid seat/back, patient weight capacity 601 pounds or more














65





seat/back, patient weight capacity 301 to 450 pounds

PA K0880 HCPCS Power wheelchair, group 4 very heavy-duty, single power option,

sling/solid seat/back, patient weight 451 to 600 pounds

PA K0884 HCPCS



pounds

PA K0885 HCPCS Power wheelchair, group 4 standard, multiple power option, captain's




PA K0890 HCPCS Power wheelchair, group 5 pediatric, single power option, sling/solid


PA K0891 HCPCS Power wheelchair, group 5 pediatric, multiple power option, sling/solid


PA K0898 HCPCS Power wheelchair, not otherwise classified

PA K0899 HCPCS Power mobility device, not coded by DME PDAC or does not meet

criteria

PA S1030 HCPCS Continuous noninvasive glucose monitoring device, purchase (for

physician interpretation of data, use CPT code)

PA S1031 HCPCS

Continuous noninvasive glucose monitoring device, rental, including

sensor, sensor replacement, and download to monitor (for physician

interpretation of data, use CPT code)

PA S1034 HCPCS

Artificial pancreas device system (e.g., low glucose suspend [LGS]

feature) including continuous glucose monitor, blood glucose device,

insulin pump and computer algorithm that communicates with all of

the devices

PA S1035 HCPCS Sensor; invasive (e.g., subcutaneous), disposable, for use with artificial

pancreas device system


66




PA S1036 HCPCS Transmitter; external, for use with artificial pancreas device system

PA S1037 HCPCS Receiver (monitor); external, for use with artificial pancreas device

system

PA S2083 HCPCS Adjustment of gastric band diameter via subcutaneous port by

injection or aspiration of saline

PA S2112 HCPCS Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte

cells)

PA S3840 HCPCS DNA analysis for germline mutations of the RET proto-oncogene for

susceptibility to multiple endocrine neoplasia type 2

PA S3841 HCPCS Genetic testing for retinoblastoma

PA S3842 HCPCS Genetic testing for Von Hippel-Lindau disease

PA S3844 HCPCS DNA analysis of the connexin 26 gene (GJB2) for susceptibility to

congenital, profound deafness

PA S3845 HCPCS Genetic testing for alpha-thalassemia

PA S3846 HCPCS Genetic testing for hemoglobin E beta-thalassemia

PA S3849 HCPCS Genetic testing for Niemann-Pick disease

PA S3850 HCPCS Genetic testing for sickle cell anemia

PA S3852 HCPCS DNA analysis for APOE epsilon 4 allele for susceptibility to Alzheimer's

disease

PA S3853 HCPCS Genetic testing for myotonic muscular dystrophy

PA S3854 HCPCS Gene expression profiling panel for use in the management of breast

cancer treatment

PA S3861 HCPCS Genetic testing, sodium channel, voltage-gated, type V, alpha subunit

(SCN5A) and variants for suspected Brugada Syndrome

PA S3865 HCPCS Comprehensive gene sequence analysis for hypertrophic

cardiomyopathy


67




PA S3866 HCPCS

Genetic analysis for a specific gene mutation for hypertrophic

cardiomyopathy (HCM) in an individual with a known HCM mutation in

the family

PA S3870 HCPCS

Comparative genomic hybridization (CGH) microarray testing for

developmental delay, autism spectrum disorder and/or intellectual

disability

PA S9988 HCPCS Services provided as part of a Phase I clinical trial

PA S9990 HCPCS Services provided as part of a Phase II clinical trial

PA S9991 HCPCS Services provided as part of a Phase III clinical trial

Documents

Medical Products and Services Requiring …...Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits