IHCP bulletin INDIANA HEALTH COVERAGE PROGRAMS BT JANUARY 6, 2015

Transcription

1 IHCP bulletin INDIANA HEALTH COVERAGE PROGRAMS BT JANUARY 6, 2015 Coverage and billing for the 2015 annual HCPCS s update The Indiana Health Coverage Programs (IHCP) has reviewed the 2015 annual Healthcare Common Coding System (HCPCS) update to determine coverage and billing guidelines. IHCP coverage and billing provided in this bulletin is effective January 1, This bulletin serves as notice of the following : Table 1: New alphanumeric and Current Procedural Terminology (CPT 1 ) s included in the 2015 annual HCPCS update, showing: Program coverage determination (PA) requirement National Drug Code () requirement Table 2: New modifiers included in the 2015 annual HCPCS update showing the modifier, description, and type. Providers should follow CPT coding guidelines for reporting services using appropriate modifiers. Table 3: Pricing s for newly covered s from Table 1 that are manually priced s. Table 4: Newly covered s from Table 1 for which separate reimbursement is allowed under revenue (RC) 636 Drugs requiring detailed coding for separate reimbursement in an outpatient setting. For reimbursement consideration, providers may bill these procedure s and the RC together, as appropriate, for dates of service (DOS) on or after January 1, Table 5: Newly covered s from Table 1 payable only when billed as a CMS-1500 claim. Table 6: Newly covered s from Table 1 payable only when billed as a UB-04 claim. Table 7: Existing IHCP-covered s with updated pricing based on modified descriptions effective January 1, Codes are payable only when billed as UB-04 claims effective January 1, The 2015 annual HCPCS and CPT s will be added to the IndianaAIM claims processing system. Established pricing will be posted on the Fee Schedule and s added to the provider Code Sets page and to the list of Codes that Require s at indianamedicaid.com. Providers may report these s for DOS on or after January 1, The standard global billing procedures and edits apply when using the new s. The 2015 annual HCPCS update also included modifications to descriptions for some existing HCPCS s. There were three IHCP-covered s for which the description modification affected reimbursement. These s along with their 1 CPT copyright 2013 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Page 1 of 2

2 modified descriptions are listed on Table 7. Updated pricing will be posted in the next monthly update to the Fee Schedule at indianamedicaid.com. These s will continue to be covered; however, effective for DOS on or after January 1, 2015, the s will be payable only when billed as UB-04 claims. Upon evaluation, it was determined that other description modifications resulted in no substantive change in meaning or intent and therefore are not addressed in this bulletin. These modifications are available for reference or download from the Centers for Medicare & Medicaid Services (CMS) website at cms.gov. The 2015 annual HCPCS update also included a list of deleted s. These s are available for reference or download from the CMS website at cms.gov. CMS has not yet published the alternative s associated with the deleted s. Once announced by CMS, the IHCP will issue a publication listing any IHCP-covered s that were deleted and for which there are associated alternative s effective January 1, QUESTIONS? If you have questions about this publication, please contact Customer Assistance at SIGN UP FOR IHCP NOTIFICATIONS To receive notices of IHCP publications, subscribe by clicking the blue subscription envelope here or on the pages of indianamedicaid.com. COPIES OF THIS PUBLICATION If you need additional copies of this publication, please download them from indianamedicaid.com. TO PRINT A printer-friendly version of this publication, in black and white and without graphics, is available for your convenience. Page 2 of 2

3 Table 1 New s included in the 2015 annual HCPCS update, effective for DOS on or after January 1, Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); with ultrasound guidance, with permanent recording and reporting Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting Ablation therapy for reduction or eradication of 1 or more bone tumors (eg, metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; cryoablation Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 1-3 ribs Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 4-6 ribs Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 7 or more ribs Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral * Covered indicates the service described for the is covered, subject to the limitations of the member s benefit package. Noncovered indicates that the IHCP does not cover the service described for the Annual HCPCS Update Tables 1 of 53

4 Table 1 New s included in the 2015 annual HCPCS update, effective for DOS on or after January 1, Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; each additional cervicothoracic or lumbosacral vertebral body (List separately in addition to for primary procedure) Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical (List separately in addition to for primary procedures) Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device * Covered indicates the service described for the is covered, subject to the limitations of the member s benefit package. Noncovered indicates that the IHCP does not cover the service described for the Annual HCPCS Update Tables 2 of 53

5 Table 1 New s included in the 2015 annual HCPCS update, effective for DOS on or after January 1, Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters, when performed Insertion of subcutaneous implantable defibrillator electrode Removal of subcutaneous implantable defibrillator electrode Repositioning of previously implanted subcutaneous implantable defibrillator electrode Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; additional prosthesis(es) during same session (List separately in addition to for primary procedure) Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; initiation, veno-venous Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; initiation, veno-arterial Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; daily management, each day, veno-venous Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; daily management, each day, veno-arterial * Covered indicates the service described for the is covered, subject to the limitations of the member s benefit package. Noncovered indicates that the IHCP does not cover the service described for the Annual HCPCS Update Tables 3 of 53

6 Table 1 New s included in the 2015 annual HCPCS update, effective for DOS on or after January 1, Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; insertion of peripheral (arterial and/or venous) cannula(e), percutaneous, birth through 5 years of age (includes fluoroscopic guidance, when performed) Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; insertion of peripheral (arterial and/or venous) cannula(e), percutaneous, 6 years and older (includes fluoroscopic guidance, when performed) Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; insertion of peripheral (arterial and/or venous) cannula(e), open, birth through 5 years of age Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; insertion of peripheral (arterial and/or venous) cannula(e), open, 6 years and older Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; insertion of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; insertion of central cannula(e) by sternotomy or thoracotomy, 6 years and older Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; reposition peripheral (arterial and/or venous) cannula(e), percutaneous, birth through 5 years of age (includes fluoroscopic guidance, when performed) * Covered indicates the service described for the is covered, subject to the limitations of the member s benefit package. Noncovered indicates that the IHCP does not cover the service described for the Annual HCPCS Update Tables 4 of 53

7 Table 1 New s included in the 2015 annual HCPCS update, effective for DOS on or after January 1, Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; reposition peripheral (arterial and/or venous) cannula(e), percutaneous, 6 years and older (includes fluoroscopic guidance, when performed) Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; reposition peripheral (arterial and/or venous) cannula(e), open, birth through 5 years of age (includes fluoroscopic guidance, when performed) Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; reposition peripheral (arterial and/or venous) cannula(e), open, 6 years and older (includes fluoroscopic guidance, when performed) Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; reposition of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age (includes fluoroscopic guidance, when performed) Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; reposition central cannula(e) by sternotomy or thoracotomy, 6 years and older (includes fluoroscopic guidance, when performed) Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of peripheral (arterial and/or venous) cannula(e), percutaneous, birth through 5 years of age * Covered indicates the service described for the is covered, subject to the limitations of the member s benefit package. Noncovered indicates that the IHCP does not cover the service described for the Annual HCPCS Update Tables 5 of 53

8 Table 1 New s included in the 2015 annual HCPCS update, effective for DOS on or after January 1, Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of peripheral (arterial and/or venous) cannula(e), percutaneous, 6 years and older Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of peripheral (arterial and/or venous) cannula(e), open, birth through 5 years of age Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of peripheral (arterial and/or venous) cannula(e), open, 6 years and older Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of central cannula(e) by sternotomy or thoracotomy, 6 years and older Arterial exposure with creation of graft conduit (eg, chimney graft) to facilitate arterial perfusion for ECMO/ECLS (List separately in addition to for primary procedure) Insertion of left heart vent by thoracic incision (eg, sternotomy, thoracotomy) for ECMO/ECLS Removal of left heart vent by thoracic incision (eg, sternotomy, thoracotomy) for ECMO/ECLS Physician planning of a patientspecific fenestrated visceral aortic endograft requiring a minimum of 90 minutes of physician time * Covered indicates the service described for the is covered, subject to the limitations of the member s benefit package. Noncovered indicates that the IHCP does not cover the service described for the Annual HCPCS Update Tables 6 of 53

9 Table 1 New s included in the 2015 annual HCPCS update, effective for DOS on or after January 1, Transcatheter placement of intravascular stent(s), intrathoracic common carotid artery or innominate artery, open or percutaneous antegrade approach, including angioplasty, when performed, and radiological supervision and interpretation Esophagoscopy, rigid, transoral with diverticulectomy of hypopharynx or cervical esophagus (eg, Zenker's diverticulum), with cricopharyngeal myotomy, includes use of telescope or operating microscope and repair, when performed Ileoscopy, through stoma; with transendoscopic balloon dilation Ileoscopy, through stoma; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed) Colonoscopy through stoma; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) Colonoscopy through stoma; with endoscopic stent placement (including pre- and post-dilation and guide wire passage, when performed) Colonoscopy through stoma; with endoscopic mucosal resection Colonoscopy through stoma; with directed submucosal injection(s), any substance Colonoscopy through stoma; with transendoscopic balloon dilation Colonoscopy through stoma; with endoscopic ultrasound examination, limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures * Covered indicates the service described for the is covered, subject to the limitations of the member s benefit package. Noncovered indicates that the IHCP does not cover the service described for the Annual HCPCS Update Tables 7 of 53

10 Table 1 New s included in the 2015 annual HCPCS update, effective for DOS on or after January 1, Colonoscopy through stoma; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures Colonoscopy through stoma; with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) Sigmoidoscopy, flexible; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed) Sigmoidoscopy, flexible; with endoscopic mucosal resection Sigmoidoscopy, flexible; with band ligation(s) (eg, hemorrhoids) Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and postdilation and guide wire passage, when performed) Colonoscopy, flexible; with endoscopic stent placement (includes pre- and post-dilation and guide wire passage, when performed) Colonoscopy, flexible; with endoscopic mucosal resection Colonoscopy, flexible; with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed * Covered indicates the service described for the is covered, subject to the limitations of the member s benefit package. Noncovered indicates that the IHCP does not cover the service described for the Annual HCPCS Update Tables 8 of 53

11 Table 1 New s included in the 2015 annual HCPCS update, effective for DOS on or after January 1, Colonoscopy, flexible; with band ligation(s) (eg, hemorrhoids) Unlisted procedure, colon Anoscopy; diagnostic, with highresolution magnification (HRA) (eg, colposcope, operating microscope) and chemical agent enhancement, including collection of specimen(s) by brushing or washing, when performed Anoscopy; with high-resolution magnification (HRA) (eg, colposcope, operating microscope) and chemical agent enhancement, with biopsy, single or multiple Ablation, 1 or more liver tumor(s), percutaneous, cryoablation Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; each additional permanent adjustable transprostatic implant (List separately in addition to for primary procedure) Myelography via lumbar injection, including radiological supervision and interpretation; cervical Myelography via lumbar injection, including radiological supervision and interpretation; thoracic Myelography via lumbar injection, including radiological supervision and interpretation; lumbosacral Myelography via lumbar injection, including radiological supervision and interpretation; 2 or more regions (eg, lumbar/thoracic, cervical/thoracic, lumbar/cervical, lumbar/thoracic/cervical) Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) unilateral; by injection(s) (includes imaging Yes No No Yes No No guidance, when performed) * Covered indicates the service described for the is covered, subject to the limitations of the member s benefit package. Noncovered indicates that the IHCP does not cover the service described for the Annual HCPCS Update Tables 9 of 53

12 Table 1 New s included in the 2015 annual HCPCS update, effective for DOS on or after January 1, Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) unilateral; by continuous infusion(s) (includes imaging guidance, when performed) Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by injections (includes imaging guidance, when performed) Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by continuous infusions (includes imaging guidance, when performed) Aqueous shunt to extraocular equatorial plate reservoir, external approach; without graft Revision of aqueous shunt to extraocular equatorial plate reservoir; without graft Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited Digital breast tomosynthesis; unilateral Digital breast tomosynthesis; bilateral Screening digital breast tomosynthesis, bilateral (List separately in addition to for primary procedure) Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine), including vertebral fracture assessment Vertebral fracture assessment via dual-energy X-ray absorptiometry (DXA) * Covered indicates the service described for the is covered, subject to the limitations of the member s benefit package. Noncovered indicates that the IHCP does not cover the service described for the Annual HCPCS Update Tables 10 of 53

13 Table 1 New s included in the 2015 annual HCPCS update, effective for DOS on or after January 1, Teletherapy isodose plan; simple (1 or 2 unmodified ports directed to a single area of interest), includes basic dosimetry calculation(s) Teletherapy isodose plan; complex (multiple treatment areas, tangential ports, the use of wedges, blocking, rotational beam, or special beam considerations), includes basic dosimetry calculation(s) Brachytherapy isodose plan; simple (calculation[s] made from 1 to 4 sources, or remote after loading brachytherapy, 1 channel), includes basic dosimetry calculation(s) Brachytherapy isodose plan; intermediate (calculation[s] made from 5 to 10 sources, or remote after loading brachytherapy, 2-12 channels), includes basic dosimetry calculation(s) Brachytherapy isodose plan; complex (calculation[s] made from over 10 sources, or remote after loading brachytherapy, over 12 channels), includes basic dosimetry calculation(s) Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; simple Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; complex Guidance for localization of target volume for delivery of radiation treatment delivery, includes intrafraction tracking, when performed Digoxin; free Valproic acid (dipropylacetic acid); free No No See Table 6- payable only as UB-04 claim No No See Table 6 payable only as UB-04 claim * Covered indicates the service described for the is covered, subject to the limitations of the member s benefit package. Noncovered indicates that the IHCP does not cover the service described for the Annual HCPCS Update Tables 11 of 53

14 Table 1 New s included in the 2015 annual HCPCS update, effective for DOS on or after January 1, Drug screen, any number of drug classes from Drug Class List A; any number of non-tlc devices or procedures, (eg, immunoassay) capable of being read by direct optical observation, including instrumented-assisted when performed (eg, dipsticks, cups, cards, cartridges) per date of service Drug screen, any number of drug classes from Drug Class List A; single drug class method, by instrumented test systems (eg, discrete multichannel chemistry analyzers utilizing immunoassay or enzyme assay), per date of service Drug screen, presumptive, single drug class from Drug Class List B, by immunoassay (eg, ELISA) or non-tlc chromatography without mass spectrometry (eg, GC, HPLC), each procedure Drug screen, any number of drug classes, presumptive, single or multiple drug class method; thin layer chromatography procedure(s) (TLC) (eg, acid, neutral, alkaloid plate), per date of service Drug screen, any number of drug classes, presumptive, single or multiple drug class method; not otherwise specified presumptive procedure (eg, TOF, MALDI, LDTD, DESI, DART), each procedure Alcohols Alcohol biomarkers; 1 or Alcohol biomarkers; 3 or more Alkaloids, not otherwise specified Amphetamines; 1 or 2 * Covered indicates the service described for the is covered, subject to the limitations of the member s benefit package. Noncovered indicates that the IHCP does not cover the service described for the Annual HCPCS Update Tables 12 of 53

15 Table 1 New s included in the 2015 annual HCPCS update, effective for DOS on or after January 1, Amphetamines; 3 or Amphetamines; 5 or more Anabolic steroids; 1 or Anabolic steroids; 3 or more Analgesics, non-opioid; 1 or Analgesics, non-opioid; Analgesics, non-opioid; 6 or more Antidepressants, serotonergic class; 1 or Antidepressants, serotonergic class; Antidepressants, serotonergic class; 6 or more Antidepressants, tricyclic and other cyclicals; 1 or Antidepressants, tricyclic and other cyclicals; Antidepressants, tricyclic and other cyclicals; 6 or more Antidepressants, not otherwise specified Antiepileptics, not otherwise specified; 1-3 * Covered indicates the service described for the is covered, subject to the limitations of the member s benefit package. Noncovered indicates that the IHCP does not cover the service described for the Annual HCPCS Update Tables 13 of 53

16 Table 1 New s included in the 2015 annual HCPCS update, effective for DOS on or after January 1, Antiepileptics, not otherwise specified; Antiepileptics, not otherwise specified; 7 or more Antipsychotics, not otherwise specified; Antipsychotics, not otherwise specified; Antipsychotics, not otherwise specified; 7 or more Barbiturates Benzodiazepines; Benzodiazepines; 13 or more Buprenorphine Cannabinoids, natural Cannabinoids, synthetic; Cannabinoids, synthetic; Cannabinoids, synthetic; 7 or more Cocaine Fentanyl * Covered indicates the service described for the is covered, subject to the limitations of the member s benefit package. Noncovered indicates that the IHCP does not cover the service described for the Annual HCPCS Update Tables 14 of 53

17 Table 1 New s included in the 2015 annual HCPCS update, effective for DOS on or after January 1, Gabapentin, non-blood Heroin metabolite Ketamine and norketamine Methadone Methylenedioxyamphetamines (MDA, MDEA, MDMA) Methylphenidate Opiates, 1 or more Opioids and opiate analogs; 1 or Opioids and Opiate analogs; 3 or Opioids and Opiate analogs; 5 or more Oxycodone Pregabalin Propoxyphene Sedative hypnotics (nonbenzodiazepines) Skeletal muscle relaxants; 1 or Skeletal muscle relaxants; 3 or more * Covered indicates the service described for the is covered, subject to the limitations of the member s benefit package. Noncovered indicates that the IHCP does not cover the service described for the Annual HCPCS Update Tables 15 of 53

18 Table 1 New s included in the 2015 annual HCPCS update, effective for DOS on or after January 1, Stimulants, synthetic Tapentadol Tramadol Stereoisomer (enantiomer) analysis, single drug class Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 7 or more FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia), gene analysis; tyrosine kinase domain (TKD) variants (eg, D835, I836) MLH1 (mutl homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; promoter methylation analysis PCA3/KLK3 (prostate cancer antigen 3 [non-protein coding]/ kallikrein-related peptidase 3 [prostate specific antigen]) ratio (eg, prostate cancer) 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 Yes No See Table 3 for Yes No See Table 3 for * Covered indicates the service described for the is covered, subject to the limitations of the member s benefit package. Noncovered indicates that the IHCP does not cover the service described for the Annual HCPCS Update Tables 16 of 53

19 Table 1 New s included in the 2015 annual HCPCS update, effective for DOS on or after January 1, 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, MYH11, ACTA2, SLC2A10, SMAD3, and MYLK Exome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis Exome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator exome (eg, parents, siblings) (List separately in addition to for primary procedure) Exome (eg, unexplained constitutional or heritable disorder or syndrome); re-evaluation of previously obtained exome sequence (eg, updated knowledge or unrelated condition/syndrome) 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 Genome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis Genome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator genome (eg, parents, siblings) (List separately in addition to for primary procedure) Genome (eg, unexplained constitutional or heritable disorder or syndrome); re-evaluation of previously obtained genome sequence (eg, updated knowledge or unrelated condition/syndrome) * Covered indicates the service described for the is covered, subject to the limitations of the member s benefit package. Noncovered indicates that the IHCP does not cover the service described for the Annual HCPCS Update Tables 17 of 53

20 Table 1 New s included in the 2015 annual HCPCS update, effective for DOS on or after January 1, 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, TMPRSS 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 Hereditary colon cancer syndromes (eg, Lynch syndrome, familial adenomatosis polyposis); genomic sequence analysis panel, must include analysis of at least 7 genes, including APC, CHEK2, MLH1, MSH2, MSH6, MUTYH, and PMS Hereditary colon cancer syndromes (eg, Lynch syndrome, familial adenomatosis polyposis); duplication/deletion gene analysis panel, must include analysis of at least 8 genes, including APC, MLH1, MSH2, MSH6, PMS2, EPCAM, CHEK2, and MUTYH Nuclear end 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, SULCG1, TAZ, TK2, and TYMP Targeted genomic sequence analysis panel, solid organ neoplasm, DNA analysis, 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 * Covered indicates the service described for the is covered, subject to the limitations of the member s benefit package. Noncovered indicates that the IHCP does not cover the service described for the Annual HCPCS Update Tables 18 of 53

21 Table 1 New s included in the 2015 annual HCPCS update, effective for DOS on or after January 1, Targeted genomic sequence analysis panel, hematolymphoid neoplasm or disorder, DNA 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 Targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA 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 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 hertoplasmy detection Whole mitochondrial genome large deletion analysis panel (eg, Kearns- Sayre syndrome, chronic progressive external ophthalmoplegia), including heteroplasmy detection, if performed 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, PRS6KA3, SLC16A2 * Covered indicates the service described for the is covered, subject to the limitations of the member s benefit package. Noncovered indicates that the IHCP does not cover the service described for the Annual HCPCS Update Tables 19 of 53

22 Table 1 New s included in the 2015 annual HCPCS update, effective for DOS on or after January 1, 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, PRS6KA3, SLC16A2, Oncology (breast), mrna, gene expression profiling by real-time RT- PCR of 21 genes, utilizing formalinfixed paraffin embedded tissue, algorithm reported as recurrence score Growth stimulation expressed gene 2 (ST2, Interleukin 1 receptor like-1) Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), low-risk types (eg, 6, 11, 42, 43, 44) Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), high-risk types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) * Covered indicates the service described for the is covered, subject to the limitations of the member s benefit package. Noncovered indicates that the IHCP does not cover the service described for the Annual HCPCS Update Tables 20 of 53

23 Table 1 New s included in the 2015 annual HCPCS update, effective for DOS on or after January 1, Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed Infectious agent antigen detection by immunoassay with direct optical observation; HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in addition to for primary procedure) Immunohistochemistry or immunocytochemistry, per specimen; each multiplex antibody stain procedure In situ hybridization (eg, FISH), per specimen; each additional single probe stain procedure (List separately in addition to for primary procedure) In situ hybridization (eg, FISH), per specimen; each multiplex probe stain procedure Morphometric analysis, in situ hybridization (quantitative or semiquantitative), manual, per specimen; each additional single probe stain procedure (List separately in addition to for primary procedure) Morphometric analysis, in situ hybridization (quantitative or semiquantitative), using computerassisted technology, per specimen; each additional single probe stain procedure (List separately in addition to for primary procedure) Morphometric analysis, in situ hybridization (quantitative or semiquantitative), using computerassisted technology, per specimen; each multiplex probe stain procedure * Covered indicates the service described for the is covered, subject to the limitations of the member s benefit package. Noncovered indicates that the IHCP does not cover the service described for the Annual HCPCS Update Tables 21 of 53

24 Table 1 New s included in the 2015 annual HCPCS update, effective for DOS on or after January 1, Morphometric analysis, in situ hybridization (quantitative or semiquantitative), manual, per specimen; each multiplex probe stain procedure Cryopreservation, mature oocyte(s) Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (HPV), 3 dose schedule, for intramuscular use Diphtheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, Haemophilus influenza type b PRP-OMP conjugate vaccine, and hepatitis B vaccine (DTaP-IPV-HibHepB), for intramuscular use Liver elastography, mechanically induced shear wave (eg, vibration), without imaging, with interpretation and report Corneal hysteresis determination, by air impulse stimulation, unilateral or bilateral, with interpretation and report Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional; implantable subcutaneous lead defibrillator system Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter; implantable subcutaneous lead defibrillator system No No See Table 4 Linked to RC 636 * Covered indicates the service described for the is covered, subject to the limitations of the member s benefit package. Noncovered indicates that the IHCP does not cover the service described for the Annual HCPCS Update Tables 22 of 53

25 Table 1 New s included in the 2015 annual HCPCS update, effective for DOS on or after January 1, Echocardiography, transesophageal (TEE) for guidance of a transcatheter intracardiac or great vessel(s) structural intervention(s) (eg, TAVR, transcathether pulmonary valve replacement, mitral valve repair, paravalvular regurgitation repair, left atrial appendage occlusion/closure, ventricular septal defect closure) (peri- and intraprocedural), real time image acquisition and documentation, guidance with quantitative measurements, probe manipulation, interpretation, and report, including diagnostic transesophageal echocardiography and, when performed, administration of ultrasound contrast, Doppler, color flow, and 3D Electrophysiologic evaluation of subcutaneous implantable defibrillator (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters Bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema assessment(s) Quantitative carotid intima media thickness and carotid atheroma evaluation, bilateral Brief emotional/behavioral assessment (eg, depression inventory, attentiondeficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, nondurable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters * Covered indicates the service described for the is covered, subject to the limitations of the member s benefit package. Noncovered indicates that the IHCP does not cover the service described for the Annual HCPCS Update Tables 23 of 53

26 Table 1 New s included in the 2015 annual HCPCS update, effective for DOS on or after January 1, Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, nondurable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude Application of topical fluoride varnish by a physician or other qualified health care professional Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following elements: multiple (two or more) chronic conditions expected Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with patient, family, or designated surrogate Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to for primary procedure) A4459 Manual pump-operated enema system, includes balloon, catheter and all accessories, reusable, any type * Covered indicates the service described for the is covered, subject to the limitations of the member s benefit package. Noncovered indicates that the IHCP does not cover the service described for the Annual HCPCS Update Tables 24 of 53

27 Table 1 New s included in the 2015 annual HCPCS update, effective for DOS on or after January 1, 2015 A4602 A7048 A9606 C2624 Replacement battery for external infusion pump owned by patient, lithium, 1.5 volt, each Vacuum drainage collection unit and tubing kit, including all supplies needed for collection unit change, for use with implanted catheter, each Radium ra-223 dichloride, therapeutic, per microcurie Implantable wireless pulmonary artery pressure sensor with delivery catheter, including all system components C9027 Injection, pembrolizumab, 1 mg C9136 C9349 Injection, factor viii, fc fusion protein, (recombinant), per i.u. Fortaderm, and fortaderm antimicrobial, any type, per square centimeter C9442 Injection, belinostat, 10 mg C9443 Injection, dalbavancin, 10 mg C9444 Injection, oritavancin, 10 mg C9446 Injection, tedizolid phosphate, 1 mg C9447 C9742 D0171 Injection, phenylephrine and ketorolac, 4 ml vial Laryngoscopy, flexible fiberoptic, with injection into vocal cord(s), therapeutic, including diagnostic laryngoscopy, if performed Re-evaluation - post-operative office visit D0351 3D photographic image D1353 Sealant repair - per tooth D6110 Implant/abutment supported removable denture for edentulous arch - maxillary No Yes No No Yes See Table 4 Linked to RC 636 No No See Table 4 Linked to RC 636 No Yes See Table 4 Linked to RC 636 No Yes See Table 4 Linked to RC 636 No Yes See Table 4 Linked to RC 636 No Yes See Table 4 Linked to RC 636 * Covered indicates the service described for the is covered, subject to the limitations of the member s benefit package. Noncovered indicates that the IHCP does not cover the service described for the Annual HCPCS Update Tables 25 of 53

28 Table 1 New s included in the 2015 annual HCPCS update, effective for DOS on or after January 1, 2015 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6549 D9219 D9931 Implant/abutment supported removable denture for edentulous arch - mandibular Implant/abutment supported removable denture for partially edentulous arch - maxillary Implant/abutment supported removable denture for partially edentulous arch - mandibular Implant/abutment supported fixed denture for edentulous arch - maxillary Implant/abutment supported fixed denture for edentulous arch - mandibular Implant/abutment supported fixed denture for partially edentulous arch - maxillary Implant/abutment supported fixed denture for partially edentulous arch - mandibular Resin retainer - for resin bonded fixed prosthesis Evaluation for deep sedation or general anesthesia Cleaning and inspection of a removable appliance D9986 Missed appointment D9987 Cancelled appointment G0276 G0277 G0279 Blinded procedure for lumbar stenosis, percutaneous imageguided lumbar decompression (PILD) or placebo-control, performed in an approved coverage with evidence development (CED) clinical trial Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval Diagnostic digital breast tomosynthesis, unilateral or bilateral (list separately in addition to G0204 or G0206) No No See Table 5 payable only as CMS-1500 claim * Covered indicates the service described for the is covered, subject to the limitations of the member s benefit package. Noncovered indicates that the IHCP does not cover the service described for the Annual HCPCS Update Tables 26 of 53

29 Table 1 New s included in the 2015 annual HCPCS update, effective for DOS on or after January 1, 2015 G0464 G0472 G0473 G6001 G6002 G6003 G6004 G6005 G6006 Colorectal cancer screening; stoolbased DNA and fecal occult hemoglobin (e.g., kras, ndrg4 and bmp3) Hepatitis C antibody screening, for individual at high risk and other covered indication(s) Face-to-face behavioral counseling for obesity, group (2-10), 30 minutes Ultrasonic guidance for placement of radiation therapy fields Stereoscopic X-ray guidance for localization of target volume for the delivery of radiation therapy Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: up to 5 mev Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 6-10 mev Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: mev Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 20 mev or greater G6007 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: up to 5 mev G6008 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 6-10 mev G6009 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: mev G6010 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 20 mev or greater No No See Table 5 payable only as CMS-1500 claim No No See Table 5 payable only as CMS-1500 claim No No See Table 5 payable only as CMS-1500 claim No No See Table 5 payable only as CMS-1500 claim No No See Table 5 payable only as CMS-1500 claim No No See Table 5 payable only as CMS-1500 claim No No See Table 5 payable only as CMS-1500 claim No No See Table 5 payable only as CMS-1500 claim No No See Table 5 payable only as CMS-1500 claim No No See Table 5 payable only as CMS-1500 claim * Covered indicates the service described for the is covered, subject to the limitations of the member s benefit package. Noncovered indicates that the IHCP does not cover the service described for the Annual HCPCS Update Tables 27 of 53