Anthem Central Region Clinical Claims Edit

Transcription

1 Please compare the claim's date of adjudication to the range of the edit in question. Prior versions, if any, can be found below. Subject: Conscious Sedation Performed with Procedures listed in Appendix G of 2009 CPT Code Book by Same Physician Edit #: 584 Effective Date: 9/20/ /31/2099 Status: Current Last Review Date: 3/7/2013 Edit (Moderate sedation services {other than those services described by codes } provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient s level of consciousness and physiological status; under 5 years of age, first 30 minutes intra-service time), (Moderate sedation services {other than those services described by codes } provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient s level of consciousness and physiological status; age 5 years of older, first 30 minutes intra-service time) and (Moderate sedation services {other than those services described by codes } provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient s level of consciousness and physiological status; each additional 15 minutes intra-service time) bundles (Placement of radiotherapy afterloading brachytherapy catheters, into breast for interstitial radioelement application-partial mastectomy-with imaging guidance), (Ablation, bone tumor(s) {e.g., osteoid osteoma, metastasis} radio frequency, percutaneous, including computed tomographic guidance), (Percutaneous vertebroplasty {bone biopsy included when performed} 1 vertebral body, unilateral or bilateral injection; thoracic), (Percutaneous vertebroplasty {bone biopsy included when performed} 1 vertebral body, unilateral or bilateral injection; lumbar), (Percutaneous vertebroplasty {bone biopsy included when performed} 1 vertebral body, unilateral or bilateral injection; each additional thoracic or lumbar vertebral body), (Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level), (Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; one or more additional levels), (Ablation, bone tumor(s) with computed tomographic guidance), (Tracheobronchoscopy or minor bronchoscopies), (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with balloon occlusion, with assessment of air leak, with administration of occlusive substance {e.g., fibrin glue}, if Page 1 of 30

2 performed), (Bronchoscopy, rigid or flexible with/without fluoroscopic guidance; with removal of foreign body), (Bronchoscopies, rigid/flexible, with/without fluoroscopic guidance, with therapeutic aspiration of tracheal tree, with balloon occlusion for air leaks, removal of bronchial valve(s)), (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed, with bronchial thermoplasty, 1 lobe), (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed, with bronchial thermoplasty, 2 or more lobes), (Catheter aspiration; tracheobronchial with fiberscope, bedside), (Pneumonostomy; with percutaneous drainage of abscess or cyst), (Biopsy, lung or mediastinum, percutaneous needle), (Insertion of indwelling tunneled pleural catheter with cuff), (Tube thoracostomy, includes water seal {e.g., for abscess, hemothorax, empyema}, when performed), , (Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial, or ventricular or atrial and ventricular), (Insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter), (Insertion or replacement of temporary transvenous dual chamber pacing electrodes), (Insertion of pacemaker pulse generator only; with existing single lead), (Insertion of pacemaker pulse generator; with existing dual leads), (Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system {includes removal of previous placed pulse generator, testing of existing lead, insertion of new lead, insertion of new pulse generator), (Insertion of a single transvenous electrode, permanent pacemaker or cardioverterdefibrilator), (Insertion of 2 transvenous electrodes, permanent pacemaker or cardioverterdefibrilator), Repair of single transvenous electrode, permanent pacemaker or pacing cardioverterdefibrilator), (Repair of 2 transvenous electrodes for permanent pacemaker or pacing cardioverdefibrilator), (Insertion of pacemaker generator only with existing multiple leads), Revision or relocation of skin pocket for pacemaker), (Revision of skin packet for cardioverter-defibrilator), (Removal of permanent pacemaker, pulse generator with replacement of pacemaker pulse generator; single lead system), (Removal of permanent pacemaker, pulse generator with replacement of pacemaker pulse generator; dual lead system), (Removal of permanent pacemaker, pulse generator with replacement of pacemaker pulse generator; multiple lead system), (Insertion of pacing cardioverter-defibrillator pulse generator only; with existing dual leads) (Insertion of pacing cardioverter-defibrillator generator only; with existing multiple leads), (Removal of permanent pacemaker pulse generator only) (Removal of transvenous pacemaker electrode(s); single lead system, atrial or ventricular), (Removal of transvenous pacemaker electrode(s); dual lead system), (Insertion of pacing cardioverter-defibrillator pulse generator only; with existing single lead) (Removal of pacing cardioverter-defibrillator pulse generator only), (Insertion or removal of single/dual chamber cardioverter-defibrillator pulse generator), (Removal of single/dual chamber pacing cardioverter-defibrillator electrodes; by transvenous extraction), (Insertion or replacement of permanent pacing cardioverter-defibrillator system with transvenous lead(s) single or dual chamber), and insertion of pulse generator), (Removal of pacing cardioverterdefibrillator pulse generator with replacement of pacing cardioverter-defibrillator pulse generator; single lead system) (Removal of pacing cardioverter-defibrillator pulse generator with replacement of pacing cardioverter-defibrillator pulse generator; multiple lead system), (Insertion of ventricular assist device, percutaneous including radiological supervision and interpretation; arterial access only), (Insertion of ventricular assist device, percutaneous including radiological supervision and Page 2 of 30

3 interpretation; both arterial and venous access, with transseptal puncture) (Removal of percutaneous ventricular assist device at separate and distinct session from insertion), (Reposition of percutaneous ventricular assist device with imaging guidance at separate and distinct session from insertion), (Transluminal balloon angioplasty, percutaneous; renal or visceral artery), (Transluminal balloon angioplasty, percutaneous; aortic), (Transluminal balloon angioplasty, percutaneous; brachiocephalic trunk or branches, each vessel) (Transluminal balloon angioplasty, percutaneous; venous), (introduction of catheter, superior or inferior vena cava), (Introduction of needle or intracatheter; retrograde brachial artery), (Introduction of needle and/or catheter, arteriovenous shunt created for dialysis {graft/fistula}; initial access with complete radiological evaluation of dialysis access, including fluoroscopy, image documentation and report {includes access of shunt, injection(s) of contrast, and all necessary imaging from the aterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava), (Introduction of needle and/or catheter, arteriovenous shunt created for dialysis {graft/fistula}; additional access for therapeutic intervention), (Introduction of catheter, aorta), (Non-selective catheter placement, thoracic aorta with angiography of the extracranial vessels, unilateral or bilateral and all associated radiological supervision and interpretati90onj, includes angiography of the cervicocerebral arch, when performed), (Selective catheter placement, common carotid or innominate artery, unilateral approach with angiography of the ipsilateral extracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed), (Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervisi99on and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed), (Selective catheter placement, carotid artery, unilateral with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of cerviocerebral arch, when performed) (Selective catheter placement, subclavian or innominate artery, unilateral, with angiography of the ipsilateral arterial circulation and all associated radiological supervision and interpretation, includes angiography of cervicocerebral arch, when performed), (Selective catheter placement, vertebral artery, unilateral, with angiography of the ipsilateral vertebral circulation and all assicuated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed), (Selective catheter placement, external carotid artery, unilateral, with angiography of ipsilateral external carotid circulation and all associated radiological supervision and interpretation), (Selective catheter placement, each intracranial branch of internal carotid or vertebral arteries, unilateral, with angiography of selected vessel circulation and all associated radiologicl supervision and interpretation {e.g., middle cerebral artery, posterior inferior cerebellar artery), (Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family), (Selective catheter placement, arterial system; initial second order abdominal, pelvic or lower extremi9ty artery branch, within a vascular family), (Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family) (Selective catheter placement, arterial system additional second order, third order, and beyond, abdominal, pelvic or lower extremity artery branch, within a vascular family), Page 3 of 30

4 36251 (Selective catheter placement {first order}, main renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture and catheter placement(s), fluoroscopy, contrast injection(s) image postprocessing, permanent recording of images and radiological supervision and interpretation, including pressure gradient measurements when performed and flush aortogram when performed; unilateral), (Selective catheter placement {first order}, main renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture and catheter placement(s), fluoroscopy, contrast injection(s) image postprocessing, permanent recording of images and radiological supervision and interpretation, including pressure gradient measurements when performed and flush aortogram when performed; bilateral), (Superselective catheter placement {one or more second order or higher renal artery(s) branches ) renal artery and any accessory renal artery(s) for renal angiography including arterial puncture, catheterization, fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; unilateral), (Superselective catheter placement {one or more second order or higher renal artery(s) branches ) renal artery and any accessory renal artery(s) for renal angiography including arterial puncture, catheterization, fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; bilateral), (Percutaneous portal vein catheterization by an method), (Insertion of non-tunneled centrally inserted venous catheter, younger than 5 year of age), (Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; younger that 5 years of age) (Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; age 5 years or older), (Insertion of tunneled centrally inserted central venous access device, with subcutaneous port, younger than 5 years of age), Insertion of tunneled centrally inserted central venous access device, with subcutaneous port, age 5 years or older), (Insertion of tunneled centrally inserted central venous access device with subcutaneous pump), (Insertion of tunneled centrally inserted central venous access device, requiring 2 catheters via 2 separate venous access sites, without subcutaneous port or pump {e..g, Tesio type catheter), (Insertion of tunneled centrally inserted central venous access device, requiring 2 catheters via 2 separate venous access sites, with subcutaneous port(s)),,36568 (Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port of pump; younger than 5 years of age), (Insertion of peripherally inserted central venous access device, with subcutaneous port; younger than 5 years of age), (Insertion of peripherally inserted central venous access device, with subcutaneous port; age 5 years of older), (Repair of central venous access device, with port or pump, central or peripheral insertion site); (Replacement, catheter only, of central venous access device, with subcutaneous port or pump, central or peripheral insertion site), (Replacement, complete, of a tunneled centrally inserted central venous access device, with/without subcutaneous port of pump, through same venous access); (Replacement, complete of peripherally inserted central venous access device, with subcutaneous port or pump through same venous access); (Removal of tunneled central access device, with subcutaneous port or pump, central or peripheral insertion); (Thrombectomy, percutaneous, arteriovenous fistula, autogenous or nonautogenous graft {includes mechanical thrombus extraction and intra-graft thrombolysis); (Revision of transverse intrahepatic portosystemic shunt(s) {TIPS} {includes venous access, hepatic and Page 4 of 30

5 portal vein catheterization, portography with hemodynamic evaluation, intrahepatic tract recanulization/ dilatation, stent placement and all associated imaging guidance and documentation}), (Primary percutaneous transluminal mechanical thrombectomy, noncoronary, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injection(s); initial vessel) (Primary percutaneous transluminal mechanical thrombectomy, noncoronary, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injection(s); second and all subsequent vessel(s) within the same vascular family), (Secondary percutaneous transluminal thrombectomy {e.g., nonprimary, mechanical snare basket, suction technique}, noncoronary, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injections, provided in conjunction with another percutaneous intervention other than primary mechanical thrombectomy) (Percutaneous transluminal mechanical thrombectomy, vein(s), intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance.), (Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance, repeat treatment on subsequent day during course of thrombolytic therapy), (Insertion of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and interpretation, intraprocedural road mapping, and imaging guidance (ultrasound and fluoroscopy} when performed), (Repositioning of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and image guidance {ultrasound and fluoroscopy), when performed), (Retrieval {removal} of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance {ultrasound and fluoroscopy} when performed), (Transcatheter retrieval, percutaneous of intravascular foreign body {e.g.,, fractured venous or arterial catheter}, includes radiological supervision and interpretation and imaging guidance {ultrasound or fluoroscopy} when performed), (Uterine fibroid embolization {UFE, embolization of the uterine arteries to treat, uterine fibroids, leiomyomata}, percutaneous approach inclusive of vascular access, vessel selection, embolization, and all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the procedure), (Transcatheter therapy, arterial infusion for thrombolysis other than coronary, any method, including radiological supervision and interpretation, initial treatment day), (Transcatheter therapy, venous infusion for thrombolysis, any method, including radiological supervision and interpretation, initial treatment day) (Transcatheter therapy, arterial or venous infusion for thrombolysis other than coronary, any method, including radiological supervision and interpretation, continued treatment on subsequent day during course of thrombolytic therapy, including follow-up catheter contrast injection, position change or exchange when performed), (Transcatheter placement of intravascular stent(s), cervical carotid artery, percutaneous; with or without distal embolic protection); (Revascularization endovascular, open or percutaneous iliac artery, unilateral, initial vessel; with transluminal angioplasty), (Revascularization endovascular, open or percutaneous iliac artery, unilateral, initial vessel; with transluminal stent placement(s) includes angioplasty within the same vessel, when performed), (Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel, with transluminal Page 5 of 30

6 angioplasty), (Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel, with transluminal stent placement(s), includes angioplasty within the same vessel, when performed), (Revascularization endovascular, open or percutaneous femoral, popliteal artery(s), unilateral; with transluminal angioplasty) (Revascularization endovascular, open or percutaneous femoral, popliteal artery(s), unilateral; with atherectomy, includes angioplasty within the same vessel, when performed), (Revascularization endovascular, open or percutaneous femoral, popliteal artery(s), unilateral; with transluminal stent placement(s0, includes angioplasty within the same vessel, when performed), (Revascularization endovascular, open or percutaneous femoral, popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy includes angioplasty within the same vessel when performed), (Revascularization endovascular open or percutaneous, tibial peroneal artery, unilateral, initial vessel; with transluminal angioplasty), (Revascularization endovascular open or percutaneous, tibial peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the same vessel when performed), (Revascularization endovascular open or percutaneous, tibial peroneal artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed), (Revascularization endovascular open or percutaneous, tibial peroneal artery, unilateral, initial vessel; with transluminal stent placement and atherectomy, includes angioplasty within the same vessel, when performed), (Revascularization, endovascular, open or percutaneous, tibia/peroneal artery, unilateral, each additional vessel with transluminal angioplasty), (Revascularization, endovascular, open or percutaneous, tibia/peroneal artery, unilateral, with atherectomy, includes angioplasty within same vessel, when performed), (Revascularization, endovascular, open or percutaneous, tibia/peroneal artery, unilateral, with transluminal stent placement(s), includes angioplasty within the same vessel when performed), (Revascularization, endovascular, open or percutaneous, tibia/peroneal artery, unilateral, with transluminal stent placement(s) and atherectomy, includes angioplasty within same vessel, when performed),????? ), (Esophagoscopies, rigid/flexible, diagnostic/therapeutic); (Upper gastrointestinal endoscopy including esophagus, stomach, and either duodenum and/or jejunum, diagnostic or therapeutic); (Endoscopic retrograde cholangiopancreatography {ERCP}-diagnostic or therapeutic); (Endoscopic cannulation of papilla with direct visualization of common bile duct(s)), (Dilation of esophagus, over guide wire, balloon or dilator); (Small intestine endoscopy, enteroscopy, beyond section portion of duodenum, not including ileum-diagnostic or therapeutic); (Small intestinal endoscopy, enteroscopy, beyond second portion of duodenum, including ileum-diagnostic or therapeutic); (Ileoscopy, through stoma-diagnostic or therapeutic); (Endoscopic evaluation of small intestine; diagnostic and biopsy); (Colonoscopy, through stoma-diagnostic or therapeutic); (Introduction of long gastrointestinal tube {e.g.,. Miller-Abbott); (Incision and drainage of appendiceal abscess; percutaneous); (Proctosigmoidoscopy, rigid,-therapeutic); (Sigmoidoscopy, flexible-therapeutic); (Colonoscopy, rigid/flexible, transabdominal via colostomy, single or multiple); (Colonoscopy, flexible, proximal to splenic flexuretherapeutic); (Biopsy of liver, needle; percutaneous); (Hepatotomy; for percutaneous drainage of abscess or cyst, one or two stages);47382 ( Ablation, 1 or more liver tumor(s), percutaneous, radiofrequency); ( Change of percutaneous biliary drainage catheter); (48511 (External drainage, pseudocyst of pancreas; percutaneous); (Drainage of peritoneal abscess or localized peritonitis, Page 6 of 30

7 exclusive of appendiceal abscess; percutaneous); (Drainage of subdiaphragmatic or subphrenic abscess; percutaneous); (Drainage of retroperitoneal abscess; percutaneous), (Placement of interstitial device(s) for radiation therapy guidance {e.g., fiducial markers, dosimeter}, percutaneous, intra-abdominal, intra-pelvic {except prostate} and/or retroperitoneum, single or multiple), (Insertion of tunneled intraperitoneal catheter {e.g., dialysis, intraperitoneal chemotherapy instillation, management of ascites}, complete procedures, including imaging guidance, catheter placement, contrast injection when performed, and radiological supervision and interpretation, percutaneous); (Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report), (Insertion of duodenostomy or jejunostomy tube percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report), (Insertion of cecostomy or other colonic tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report), (Conversion of gastrostomy tube to gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report), (Drainage of perirenal or renal abscess; percutaneous); (Renal biopsy, percutaneous, by trocar or needle), (Removal and/or replacement of internally dwelling stent via percutaneous approach, including radiological supervision and interpretation); (Removal {via snare/capture} and replacement of internally dwelling ureteral stent via transurethral approach, without use of cystoscopy, including radiological supervision and interpretation), (Removal {via snare/capture} of internally dwelling ureteral stent via transurethral approach, without use of cystoscopy, including radiological supervision and interpretation); (Removal and replacement of externally accessible transnephric ureteral stent, requiring fluoroscopic guidance, including radiological supervision and interpretation), (Ablation, one or more renal tumor(s) percutaneous, unilateral, radiofrequency); (Ablation, renal tumor(s), unilateral, percutaneous cryotherapy); (Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy); (Drainage of pelvic abscess, transvaginal or transrectal approach percutaneous); (Ciliary body destruction; cryotherapy); (Otoplasty, protruding ear, with or without size reduction); (Radiation treatment delivery, stereotactic radiosurgery {SRS} complete course of treatment of cranial lesion(s) consisting of 1 session, multi-source Cobalt 60 based); (Hyperthermia, externally generated or generated by interstitial probes); (Temporary transcutaneous pacing); (Cardioversion, elective, electrical conversion of arrhythmiaexternal or internal); (Percutaneous transluminal coronary thrombectomy); (Transcatheter placement of radiation delivery device for subsequent coronary intravascular brachytherapy); (thrombolysis, coronary, by intracoronary infusion, includ8ing selective coronary angiography); (Intravascular ultrasound (coronary vessel or graft) during diagnostic evaluation and/or therapeutic intervention, including imaging supervision, interpretation and report-initial and each additional vessel); (Percutaneous balloon valvuloplasty; aortic or mitral valve); (Echocardiography, transesophageal, real time with image documentation, including probe placement, image, interpretation and report); (Transesophageal echocardiography for congenital cardiac anomalies-probe placement, image acquisition, interpretation and report); (Echocardiography, transesophageal {TEE} for monitoring purposes, including probe placement, real time, image acquisition and interpretation leading to ongoing assessment of cardiac pumping function and to therapeutic measures on an immediate time basis); ( Right heart catheterization including Page 7 of 30

8 measurement(s) of oxygen saturation and cardiac output when performed); (Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed); (Combined right and left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed); (Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation); Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) {internal mammary, free arterial, venous graft(s)} including intraprocedural injection(s) for bypass graft angiography), (Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right heart catheterization); (Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) \{ internal mammary, free arterial, venous graft(s) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization); (Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed); (Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) {internal mammary, free arterial, venous graft(s)} with bypass graft angiography); (Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed), (Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural inject5ion(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) {internal mammary, free arterial, venous graft(s) with bypass graft angiography); (Left heart catheterization by transseptal puncture through intact septum or by transapical puncture); (Pharmacologic agent administration {e.g., inhaled nitric oxide, intravenous infusion of nitroprusside, dobutamine, milrinone, or other agent} including assessing hemodynamic measurement before, during, after and repeat pharmacologic agent administration, when performed); (Physiologic exercise study {e.g., bicycle or arm ergometry including assessing hemodynamic measurements before and after); (Endomyocardial biopsy); (Right heart catheterization, for congenital cardiac anomalies); (Indicator dilution studies such as dye or thermal dilution, including arterial and/or venous catheterization ; with cardiac output measurement and subsequent measurement); (Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective coronary angiography during congenital heart catheterization); (Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective opacification of aortocoronary venous or arterial bypass graft(s) {e.g., aortocoronary saphenous vein, free radial artery, or free mammary artery graft} to Page 8 of 30

9 one or more coronary arteries and in situ arterial conduits {e.g., internal mammary}, whether native or used for bypass to one or more coronary arteries during congenital heart catheterization, when performed); (Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective left ventricular or left atrial angiography); (Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective right ventricular or right atrial angiography); (Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for supravalvular aortography); (Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for pulmonary angiography); (Intravascular Doppler velocity and/or pressure derived coronary flow reserve measurement {coronary vessel or graft} during coronary angiography including pharmacologically induced stress; initial and each additional vessel); (Intraventricular and/or intra-atrial mapping of tachycardia site(s) with catheter manipulation to record from multiple sites to identify origin of tachycardia); (Intracardiac electrophysiologic 3-dimensional mapping); Esophageal recording of atrial electrogram with or without ventricular electrogram and with pacing); (Induction of arrhythmia by electrical pacing); (Comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording, including insertion and repositioning of electrode catheters, without induction or attempted induction of arrhythmia); (Comprehensive electrophysiologic evaluation including insertion and reposition of multiple electrode catheters, with induction or arrhythmia-w right atrial pacing, right ventricular pacing and recording, His recording); (Electrophysiologic follow-up study with pacing and recording to test effectiveness of therapy, including induction or attempted induction of arrhythmia); (Electrophysiologic evaluation of single or dual chamber pacing cardioverter-defibrillator leads including defibrillation threshold evaluation (induction of arrhythmia, evaluation of sensing and pacing for arrhythmia termination) at time of initial implantation or replacement;) (Electrophysiologic evaluation of single or dual chamber pacing cardioverterdefibrillator leads including defibrillation threshold evaluation (induction of arrhythmia, evaluation of sensing and pacing for arrhythmia termination) at time of initial implantation or replacement; with testing of single or dual chamber pacing cardioverter-defibrillator pulse generator); (Electrophysiologic evaluation of single or dual chamber pacing cardioverter-defibrillator (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing and pacing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters); (Intracardiac catheter ablation of atrioventricular node function, atrioventricular conduction for creation of complete heart block, with or without temporary pacemaker placement); (Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction of attempted induction of an arrhythmia with right atrial pacing and recording, right ventricular pacing and recording, His recording with intracardiac catheter ablation of arrhythmogenic focus; with treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathway, accessory atrioventricular connection, cavo-tricuspid isthmus or other single atrial focus or source of atrial reentry); (Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction of attempted induction of an arrhythmia with right atrial pacing and recording, right ventricular pacing and recording, His recording with intracardiac catheter ablation of arrhythmogenic focus; with treatment of ventricular tachycardia or focus of ventricular ectopy Page 9 of 30

10 including intracardiac electrophysiologic 3D mapping, when performed, and left ventricular pacing and recording, when performed); (Intracardiac catheter ablation of discrete mechanism of arrhythmia which is distinct from the primary ablated mechanism, including repeat diagnostic maneuvers, to treat a spontaneous or induced arrhythmia); (Comprehensive electrophysiologic evaluation including transseptal catheterizations, insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia with atrial recording and pacing, when possible, right ventricular pacing and recording, His bundle recording with intracardiac catheter ablation of arrhythmogenic focus, with treatment of atrial fibrillation by ablation by pulmonary vein isolation); (Additional linear of fiscal intracardiac catheter ablation of the left or right atrium for treatment of atrial fibrillation remaining after completion of pulmonary vein isolation); (Measurement of spirometric forced expiratory flows in an infant or child through 2 years of age); (Measurement of spirometric; forced expiratory flows, before and after bronchodilator, in an infant or child through 2 years of age); (Measurement of lung volumes {i.e., functional residual capacity [FRC], forced vital capacity [FVC], and expiratory reserve volume [ERV] in an infant or child through 2 years of age); 0008T (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate, with suturing of the esophagogastric junction); 0200T (Percutaneous sacral augmentation {sacroplasty}, unilateral injection(s), including the use of a balloon or mechanical device, when used 1 or more needles); 0201T (Percutaneous sacral augmentation {sacroplasty} bilateral injections, including the use of a balloon or mechanical device, when used 2 or more needles); 0282T (Percutaneous or open implantation of neurostimulator electrode array(s), subcutaneous {peripheral subcutaneous field stimulation}, including imaging guidance, when performed, cervical, thoracic or lumbar; for trail, including removal at the conclusion of trail period); 0283T (Percutaneous or open implantation of neurostimulator electrode array(s), subcutaneous {peripheral subcutaneous field stimulation}, including imaging guidance, when performed, cervical, thoracic or lumbar; permanent, with implantation of a pulse generator); 0284T (Revision or removal of pulse generator or electrodes, including imaging guidance, when performed, including addition of new electrodes, when performed); 0291T (Intravascular optical coherence tomography {coronary native vessel or graft} during diagnostic evaluation and/or therapeutic intervention, including imaging supervision, interpretation and report; initial vessel); 0292T (Intravascular optical coherence tomography {coronary native vessel or graft} during diagnostic evaluation and/or therapeutic intervention, including imaging supervision, and interpretation and report; each additional vessel); 0293T (Insertion of left atrial hemodynamic monitor; complete system, includes implanted communication module and pressure sensor lead in left atrium including transseptal access, radiological supervision and interpretation, and associated injection procedures, when performed), 0294T (Insertion of left atrial hemodynamic monitor; pressure sensor lead at time of insertion of pacing cardioverter-defibrillator pulse generation including radiological supervision and interpretation and associated injection procedures, when performed); 0301T Destruction/reduction of malignant breast tumor with externally applied focused microwave, including interstitial placement of disposable catheter with combined temperature monitoring probe and microwave focusing sensocatheter under ultrasound thermotherapy guidance); 0302T (Insertion or removal and replacement of intracardiac ischemia monitoring system including imaging supervision and interpretation when performed and intraoperative interrogation and programming when performed; complete system {includes device and electrode}); 0303T (Insertion or removal and replacement of intracardiac ischemia monitoring system including Page 10 of 30

11 imaging supervision and interpretation when performed and intraoperative interrogation and programming when performed; electrode only); 0304T Insertion or removal and replacement of intracardiac ischemia monitoring system including imaging supervision and interpretation when performed and intraoperative interrogation and programming when performed; device only) 0307T (Removal of intracardiac ischemia monitoring device) and 0308T (Arthrodesis, presacral interbody technique, including disc space preparation, discectomy; with posterior instrumentation, with image guidance, includes bone graft, when performed, lumbar, L4-L5 interspace). CODE RULE CODE Incidental Page 11 of 30

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15 Rationale for Edit: T-0201T 0282T-0284T 0291T-0294T 0301T-0304T 0307T-0308T Anthem Central Region bundles 99143, and with 19298, 20982, , , , , 31634, 31635, , , 31725, 32201, 32405, , 32553, , , , 33214, , 33221, , , , , , , , , 36010, 36140, , 36200, , , , 36481, 36555, , 36576, 36578, , 36585, 36590, 36870, 37183, , , 37203, 37210, , , , , , 43273, , , , , , , , 44397, 44500, 44901, , , 45315, 45317, , 45327, , , 45345, 45355, , , 47000, 47011, 47382, 47525, 48511, 49201, 49041, 49061, , 50021, 50200, , , 50592, 50593, 57155, 58823, 66720, 69300, 77371, , , , , , , 92941, , 92953, , 92973, 92974, 92975, , , 92986, 92987, , , 93318, , 93505, 93530, , , , 93609, 93613, , 93618, 93619, , 93624, , , , , 0200T-0201T, 0282T-0284T, 0291T-0294T, 0301T-0304T and 0307T-0308T. Based on 2013 CPT Manual, it states: The following list of procedures includes conscious sedation as an inherent part of providing the procedure. These codes are identified in the CPT codebook with a symbol. Since these services include moderate sedation, it is not appropriate for the same physician or other qualified health care professional to report both the service and the sedation It is expected that if conscious sedation is provided to the patient as part of one of these services, it is provided by the same physician or other qualified health care provider professional who is providing the service. Page 15 of 30

16 Therefore, if 99143, or is submitted with any of these procedures that includes conscious sedation as an inherent component of providing the procedure (with 19298, 20982, , , , , 31634, 31635, , , 31725, 32201, 32405, , 32553, , , , 33214, , 33221, , , , , , , , , 36010, 36140, , 36200, , , , 36481, 36555, , 36576, 36578, , 36585, 36590, 36870, 37183, , , 37203, 37210, , , , , , 43273, , , , , , , , 44397, 44500, 44901, , , 45315, 45317, , 45327, , , 45345, 45355, , , 47000, 47011, 47382, 47525, 48511, 49201, 49041, 49061, , 50021, 50200, , , 50592, 50593, 57155, 58823, 66720, 69300, 77371, , , , , , , 92941, , 92953, , 92973, 92974, 92975, , , 92986, 92987, , , 93318, , 93505, 93530, , , , 93609, 93613, , 93618, 93619, , 93624, , , , , 0200T-0201T, 0282T-0284T, 0291T-0294T, 0301T-0304T and 0307T-0308T) only the procedure (with 19298, 20982, , , , , 31634, 31635, , , 31725, 32201, 32405, , 32553, , , , 33214, , 33221, , , , , , , , , 36010, 36140, , 36200, , , , 36481, 36555, , 36576, 36578, , 36585, 36590, 36870, 37183, , , 37203, 37210, , , , , , 43273, , , , , , , , 44397, 44500, 44901, , , 45315, 45317, , 45327, , , 45345, 45355, , , 47000, 47011, 47382, 47525, 48511, 49201, 49041, 49061, , 50021, 50200, , , 50592, 50593, 57155, 58823, 66720, 69300, 77371, , , , , , , 92941, , 92953, , 92973, 92974, 92975, , , 92986, 92987, , , 93318, , 93505, 93530, , , , 93609, 93613, , 93618, 93619, , 93624, , , , , 0200T-0201T, 0282T-0284T, 0291T-0294T, 0301T-0304T and 0307T-0308T) reimburses. Reference Information: 1. American Medical Association. Appendix G Summary of CPT codes that including Moderate (Conscious Sedation). Current Procedural Terminology Please compare the claim's date of adjudication to the range of the edit in question. Prior versions, if any, can be found below. Page 16 of 30

17 Subject: Conscious Sedation Performed with Procedures listed in Appendix G of 2009 CPT Code Book by Same Physician Edit #: 584 Effective Date: 1/16/2009-9/19/2013 Status: Prior Last Review Date: 11/13/2008 Edit (Moderate sedation services {other than those services described by codes } provided by the same physician performing the diagnostic or therapeutic service that the sedation support, requiring the presence of an independent trained observer to assist in the monitoring of the patient s level of consciousness and physiological status; under 5 years of age, first 30 minutes intra-service time), (Moderate sedation services {other than those services described by codes } provided by the same physician performing the diagnostic or therapeutic service that the sedation support, requiring the presence of an independent trained observer to assist in the monitoring of the patient s level of consciousness and physiological status; age 5 years of older, first 30 minutes intra-service time) and (Moderate sedation services {other than those services described by codes } provided by the same physician performing the diagnostic or therapeutic service that the sedation support, requiring the presence of an independent trained observer to assist in the monitoring of the patient s level of consciousness and physiological status; each additional 15 minutes intra-service time) bundles (Placement of radiotherapy afterloading brachytherapy catheters, into breast for interstitial radioelement application-partial mastectomy-with imaging guidance), (Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level), (Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; one or more additional levels), (Ablation, bone tumor(s) with computed tomographic guidance), (Tracheobronchoscopy or minor bronchoscopies), (Bronchoscopy, rigid or flexible with/without fluoroscopic guidance; with removal of foreign body), (Bronchoscopies, rigid/flexible, with/without fluoroscopic guidance, with therapeutic aspiration or injection of contrast material for bronchography), (Catheter aspiration; tracheobronchial with fiberscope, bedside), (Pneumonostomy; with percutaneous drainage of abscess or cyst), (Insertion of indwelling tunneled pleural catheter with cuff), (Tube thoracostomy, includes water seal {e.g., for abscess, hemothorax, empyema}, when performed), (Pericardiocentesis; initial or subsequent), (Insertion or replacement of permanent/temporary pacemaker w transverse electrode(s)- atrial and/or ventricular-single or dual chamber, pacing electrodes or pulse generator), (Upgrade of implanted pacemaker system), (Insertion or repair of transvenous electrode; single or dual chamber, permanent pacemaker or pacing cardioverter-defibrillator), (Revision or relocation of skin pocket for pacemaker or pacing cardioverter-defibrillator), (Removal of permanent pacemaker, pulse generator, or pacemaker electrodes-single/dual lead system), Page 17 of 30