INDIANA HEALTH COVERAGE PROGRAMS

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1 INDIANA HEALTH COVERAGE PROGRAMS PROVIDER CODE TABLES Note: Due to possible changes in Indiana Health Coverage Programs (IHCP) policy or national coding updates, inclusion of a code on the code tables does not necessarily indicate current coverage. See IHCP Banner Pages and Bulletins and the IHCP Fee Schedule for updates to coding, coverage, and benefit information. Previous versions of code tables are archived for purposes of historical reference. For information about using these code tables, see the Surgical Services provider reference module. Provider Preventable Conditions Table 1 ICD-10 Diagnosis Codes for Provider Preventable Conditions Bariatric Surgery Table 2 s for Bariatric Surgery Implantable Cardioverter Defibrillator Table 3 s for Implantable Cardioverter Defibrillator Services Table 4 s for the Implantable Cardioverter Defibrillator Device Implantable Infusion Pumps Table 5 s for Implantable Infusion Pumps and Services Pacemakers Table 6 s for Pacemakers Patient-Activated Event Recorder Implantable Loop Recorder Table 7 s for the Implantable Loop Recorder System Phrenic Nerve Stimulator Table 8 ICD-10 Diagnosis Codes for the Phrenic Nerve Stimulator Table 9 ICD-10 s for Phrenic Nerve Stimulator Services Table 10 HCPCS and CPT s for Phrenic Nerve Stimulator Services Spinal Cord Stimulator (SCS) Table 11 ICD-10 Diagnosis Codes for SCS Table 12 s for SCS Services Table 13 s for SCS Device and Components Published: October 24,

2 Stents Table 14 ICD-10 Diagnosis Codes for Coverage of Stent Insertion Transcatheter Aortic Valve Replacement/Implantation (TAVR/TAVI) Table 15 s for TAVR/TAVI Vagus Nerve Stimulator (VNS) Table 16 ICD-10 Diagnosis Codes for VNS Services Table 17 ICD-10 s VNS Services Table 18 CPT s for VNS Services Table 19 s for Additional Reimbursement for the VNS Device and Components (Outpatient Only) Table 20 Surgeon s for VNS Services Table 21 Neurologist s for VNS Services Ventricular Assist Device (VAD) Table 22 ICD-10 s for VAD Services Table 23 CPT s for VAD Services Table 24 VAD Patient Supplies and Replacement Equipment s That Require Prior Authorization Table 1 ICD-10 Diagnosis Codes for Provider Preventable Conditions Diagnosis Code Y62.0 Failure of sterile precautions during surgical operation Y62.1 Failure of sterile precautions during infusion or transfusion Y62.2 Failure of sterile precautions during kidney dialysis and other perfusion Y62.3 Failure of sterile precautions during injection or immunization Y62.4 Failure of sterile precautions during endoscopic examination Y62.5 Failure of sterile precautions during heart catheterization Y62.6 Failure of sterile precautions during aspiration, puncture, and other catheterization Y62.8 Failure of sterile precautions during other surgical and medical care Y62.9 Failure of sterile precautions during unspecified surgical and medical care Y63.0 Excessive amount of blood or other fluid given during transfusion or infusion Y63.1 Incorrect dilution of fluid used during infusion Y63.2 Overdose of radiation given during therapy Y63.3 Inadvertent exposure of patient to radiation during medical care Y63.4 Failure in dosage in electroshock or insulin-shock therapy Y63.5 Inappropriate temperature in local application and packing Y63.6 Underdosing and nonadministration of necessary drug, medicament or biological substance Y63.8 Failure in dosage during other surgical and medical care Y63.9 Failure in dosage during unspecified surgical and medical care Y64.0 Contaminated medical or biological substance, transfused or infused Y64.1 Contaminated medical or biological substance, injected or used for immunization Published: October 24,

3 Table 1 ICD-10 Diagnosis Codes for Provider Preventable Conditions Diagnosis Code Y64.8 Contaminated medical or biological substance administered by other means Y64.9 Contaminated medical or biological substance administered by unspecified means Y65.0 Mismatched blood in transfusion Y65.1 Wrong fluid used in infusion Y65.2 Failure in suture or ligature during surgical operation Y65.3 Endotracheal tube wrongly placed during anesthetic procedure Y65.4 Failure to introduce or to remove other tube or instrument Y65.51 Performance of wrong operation (procedure) on correct patient (existing code) Y65.52 Performance of operation (procedure) on patient not scheduled for surgery Y65.53 Performance of correct operation (procedure) on wrong side/body part Y65.8 Other specified misadventures during surgical and medical care Y66 Y69 Nonadministration of surgical and medical care Unspecified misadventure during surgical and medical care Table Revision History October 1, 2016, update: Added (effective October 1, 2016): Y62.0, Y62.1, Y62.2, Y62.3, Y62.4, Y62.5, Y62.6, Y62.8, Y62.9, Y63.0, Y63.1, Y63.2, Y63.3, Y63.4, Y63.5, Y63.6, Y63.8, Y63.9, Y64.0, Y64.1, Y64.8, Y64.9, Y65.0, Y65.1, Y65.2, Y65.3, Y65.4, Y65.8, Y66, Y69 Note: Table 2 s for Bariatric Surgery For codes marked with an asterisk (*), the IHCP does not provide separate reimbursement for procedure code S2083 during the 90-day global period Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less) Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption 43770* Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components) 43771* Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only 43773* Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (i.e., Published: October 24,

4 Note: Table 2 s for Bariatric Surgery For codes marked with an asterisk (*), the IHCP does not provide separate reimbursement for procedure code S2083 during the 90-day global period. sleeve gastrectomy) Gastric restrictive procedure, without gastric bypass, for morbid obesity; verticalbanded gastroplasty Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch) Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric band (separate procedure) 43886* Gastric restrictive procedure, open; revision of subcutaneous port component only Gastric restrictive procedure, open; removal of subcutaneous port component only 43888* Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only Unlisted procedure, stomach Table 3 s for Implantable Cardioverter Defibrillator Services Insertion of pacemaker pulse generator only; with existing single lead Insertion of a single transvenous electrode, permanent pacemaker, or cardioverterdefibrillator Insertion of 2 transvenous electrodes, permanent pacemaker, or cardioverterdefibrillator Insertion of pacing cardioverter-defibrillator pulse generator only; with existing single lead Insertion or replacement of permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber 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 Published: October 24,

5 Table 3 s for Implantable Cardioverter Defibrillator Services Repositioning of previously implanted subcutaneous implantable defibrillator electrode 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 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) Table Revision History July 1, 2016, update: Added (effective July 1, 2016): 33270, 33271, 33272, 33273, 93260, 93261, Table 4 s for the Implantable Cardioverter Defibrillator Device C1721 C1722 C1777 C1779 C1882 C1895 C1896 C1898 C1899 C1900 Cardioverter-defibrillator, dual chamber (implantable) Cardioverter-defibrillator, single chamber (implantable) Lead, cardioverter-defibrillator, endocardial single coil (implantable) Lead, pacemaker, transvenous VDD single pass Cardioverter-defibrillator, other than single or dual chamber (implantable) Lead, cardioverter-defibrillator, endocardial dual coil (implantable) Lead, cardioverter-defibrillator, other than endocardial single or dual coil (implantable) Lead, pacemaker, other than transvenous VDD single pass Lead, pacemaker/cardioverter-defibrillator combination (implantable) Lead, left ventricular coronary venous system Published: October 24,

6 Table 5 s for Implantable Infusion Pumps and Services Insertion of implantable intra-arterial infusion pump Revision of implantable intra-arterial infusion pump Removal of implantable intra-arterial infusion pump Implantation, revision, or repositioning of tunneled intrathecal or epidural catheter for long-term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy Implantation, revision, or repositioning of tunneled intrathecal or epidural catheter for long-term medication administration via an external pump or implantable reservoir/infusion pump; with laminectomy Removal of previously implanted intrathecal or epidural catheter Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir Implantation or replacement of device for intrathecal or epidural drug infusion; nonprogrammable pump Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming Removal of subcutaneous reservoir or pump, previously implanted for intrathecal or epidural infusion Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); without reprogramming Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming E0782 Infusion pump, implantable, nonprogrammable (includes all components, such as; pump, catheter, connectors, etc) E0783 Infusion pump system, implantable, programmable (includes all components, such as; pump, catheter, connectors, etc.) C1785 C1786 C2621 Table 6 s for Pacemakers Pacemaker, dual chamber, rate-responsive (implantable) Pacemaker, single chamber, rate-responsive (implantable) Pacemaker, other than single or dual chamber (implantable) Table Revision History July 7, 2016, update: Removed (effective July 7, 2016): C2619, C2620 Published: October 24,

7 Table 7 s for the Implantable Loop Recorder System Implantation of patient-activated cardiac event recorder Removal of an implantable, patient-activated cardiac event recorder 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 loop recorder system. E0616 Implantable cardiac event recorder with memory, activator, and programmer. (The programmer is furnished by the manufacturer, to the physician, for use in the office for reading saved information in the recorder.) E1399* Durable medical equipment, not otherwise classified * Use for billing replacement recorder activator Table 8 ICD-10 Diagnosis Codes for the Phrenic Nerve Stimulator Reviewed/Updated: October 1, 2017 Diagnosis Code G12.20 Motor neuron disease, unspecified G12.21 Amyotrophic lateral sclerosis G12.22 Progressive bulbar palsy G12.23 Progressive spinal muscle atrophy G12.24 Pulmonary hypertension, unspecified G12.25 Secondary pulmonary arterial hypertension G12.29 Other motor neuron disease G47.34 Idiopathic sleep related nonobstructive alveolar hypoventilation G47.35 Congenital central alveolar hypoventilation syndrome G82.50 Quadriplegia, unspecified G82.51 Quadriplegia C1-C4, complete G82.52 Quadriplegia C1-C4, incomplete Table Revision History October 1, 2017, update: Added (effective October 1, 2017): G12.23, G12.24, G12.25 Published: October 24,

8 Table 9 ICD-10 s for Phrenic Nerve Stimulator Services 0BHT0MZ 0BHT3MZ 0BHT4MZ Reviewed/Updated: October 1, 2017 Insertion of diaphragmatic pacemaker lead into diaphragm, open approach Insertion of diaphragmatic pacemaker lead into diaphragm, percutaneous approach Insertion of diaphragmatic pacemaker lead into diaphragm, percutaneous endoscopic approach Table Revision History October 1, 2017, update: Added (effective October 1, 2017): 0BHT0MZ, 0BHT3MZ, 0BHT4MZ Removed (effective October 1, 2017): 0BHR0MZ, 0BHR3MZ, 0BHR4MZ, 0BHS0MZ, 0BHS3MZ, 0BHS4MZ Table 10 HCPCS 1 and CPT 2 s for Phrenic Nerve Stimulator Services Incision for implantation of neurostimulator electrode array; peripheral nerve Incision for implantation of neurostimulator electrode array; neuromuscular Revision or removal of peripheral neurostimulator electrode array Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); simple or complex brain, spinal cord, or peripheral (ie, cranial nerve, peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, without reprogramming Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour L8680 Implantable neurostimulator electrode, each L8681 Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only L8682 Implantable neurostimulator radiofrequency receiver L8683 Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver L8685 Implantable neurostimulator pulse generator, single array, rechargeable, includes extension L8686 Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension 1 Healthcare Common Procedure Coding System. 2 Current Procedural Terminology. CPT copyright 2016 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Published: October 24,

9 Table 10 HCPCS 1 and CPT 2 s for Phrenic Nerve Stimulator Services L8687 L8688 L8689 Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension External recharging system for battery (internal) for use with implantable neurostimulator, replacement Table 11 ICD-10 Diagnosis Codes for SCS Diagnosis Code A39.0 Meningococcal meningitis E10.40 Type 1 diabetes mellitus with diabetic neuropathy, unspecified E10.65 Type 1 diabetes mellitus with hyperglycemia E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified E11.65 Type 2 diabetes mellitus with hyperglycemia G54.0 G54.9 Nerve root and plexus disorders G55 Nerve root and plexus compressions in diseases classified elsewhere G56.40 Causalgia of unspecified upper limb G56.41 Causalgia of right upper limb G56.42 Causalgia of left upper limb G56.43 Causalgia of bilateral upper limbs G56.80 Other specified mononeuropathies of unspecified upper limb G56.81 Other specified mononeuropathies of right upper limb G56.82 Other specified mononeuropathies of left upper limb G56.83 Other specified mononeuropathies of bilateral upper limb G56.90 Unspecified mononeuropathy of unspecified upper limb G56.91 Unspecified mononeuropathy of right upper limb G56.92 Unspecified mononeuropathy of left upper limb G56.93 Unspecified mononeuropathy of bilateral upper limb G57.70 Causalgia of unspecified lower limb G57.71 Causalgia of right lower limb G57.72 Causalgia of left lower limb G57.73 Causalgia of bilateral lower limb G57.80 Other mononeuropathies of unspecified lower limb G57.81 Other mononeuropathies of right lower limb G57.82 Other mononeuropathies of left lower limb Published: October 24,

10 Diagnosis Code Table 11 ICD-10 Diagnosis Codes for SCS G57.83 Other mononeuropathies of bilateral lower limb G57.93 Unspecified mononeuropathy of bilateral lower limb G90.50 Complex regional pain syndrome I, unspecified G Complex regional pain syndrome I of right upper limb G Complex regional pain syndrome I of left upper limb G Complex regional pain syndrome I of upper limb, bilateral G Complex regional pain syndrome I of unspecified upper limb G Complex regional pain syndrome I of right lower limb G Complex regional pain syndrome I of left lower limb G Complex regional pain syndrome I of lower limb, bilateral G Complex regional pain syndrome I of unspecified lower limb G90.59 Complex regional pain syndrome I of other specified site I20.0 Unstable angina I20.1 Angina pectoris with documented spasm I20.8 Other forms of angina pectoris I20.9 Angina pectoris, unspecified S S S S S S S S S S S S S S S S S S S S S S S34.01X S34.02X Unspecified injury of cervical spinal cord Complete lesion of cervical spinal cord Central cord syndrome of cervical spinal cord Anterior cord syndrome of cervical spinal cord Brown Sequard syndrome of cervical spinal cord Other incomplete lesions of cervical spinal cord Unspecified injury of the thoracic spinal cord Complete lesion of the thoracic spinal cord Anterior cord syndrome of the thoracic spinal cord Brown Sequard syndrome of the thoracic spinal cord Other incomplete lesions of the thoracic spinal cord Concussion and edema of lumbar spinal cord Concussion and edema of sacral spinal cord Published: October 24,

11 Diagnosis Code S S S S S S Table 11 ICD-10 Diagnosis Codes for SCS Unspecified injury of lumbar spinal cord Complete lesion of lumbar spinal cord Incomplete lesion of lumbar spinal cord S Complete lesion of sacral spinal cord S Incomplete lesion of sacral spinal cord S Unspecified injury to sacral spinal cord S34.3XX Injury of cauda equina Table Revision History October 1, 2016, update: Added (effective October 1, 2016): G56.43, G56.83, G56.93, G57.73, G57.83, G57.93 Table 12 s for SCS Services Note: Prior authorization is required for codes with asterisk (*) * Percutaneous implantation of neurostimulator electrode array, epidural Laminectomy for implantation of neurostimulator electrodes, epidural Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed Revision or removal including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s) or plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed 63685* Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling Revision or removal of implanted spinal neurostimulator receiver Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); simple or complex brain, spinal cord, or peripheral (ie, cranial nerve, peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, without reprogramming Published: October 24,

12 Table 12 s for SCS Services Note: Prior authorization is required for codes with asterisk (*) Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); simple spinal cord, or peripheral (ie, peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex spinal cord, or peripheral (ie, peripheral nerve, sacral nerve, neuromuscular) (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, first hour Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex spinal cord, or peripheral (ie, peripheral nerve, sacral nerve, neuromuscular) (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure) Table 13 s for SCS Device and Components Note: Prior authorization is required for codes with asterisk (*). L8680* Implantable neurostimulator electrode, each L8681* Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only L8682* Implantable neurostimulator radiofrequency receiver L8683* Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver L8685* Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension L8686* Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension L8687* Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension L8688* Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension L8689* External recharging system for battery (internal) for use with implantable neurostimulator, replacement only L8695 External recharging system for battery (external) for use with implantable neurostimulator; replacement only. Published: October 24,

13 Diagnosis Code Table 14 ICD-10 Diagnosis Codes for Coverage of Stent Insertion I Cerebral infarction due to thrombosis of right carotid artery I Cerebral infarction due to thrombosis of left carotid artery I Cerebral infarction due to thrombosis of bilateral carotid arteries I Cerebral infarction due to thrombosis of unspecified carotid artery I Cerebral infarction due to embolism of right carotid artery I Cerebral infarction due to embolism of left carotid artery I Cerebral infarction due to embolism of bilateral carotid arteries I Cerebral infarction due to unspecified occlusion or stenosis of right carotid arteries I Cerebral infarction due to unspecified occlusion or stenosis of left carotid arteries I Cerebral infarction due to unspecified occlusion or stenosis of bilateral carotid arteries I Cerebral infarction due to unspecified occlusion or stenosis of unspecified carotid arteries I63.59 Cerebral infarction due to unspecified occlusion or stenosis of other cerebral artery I65.21 Occlusion and stenosis of right carotid artery I65.22 Occlusion and stenosis of left carotid artery I65.23 Occlusion and stenosis of bilateral carotid artery I65.29 Occlusion and stenosis of unspecified carotid artery I65.8 Occlusion and stenosis of other precerebral arteries Table Revision History October 1, 2016, update: Added (effective October 1, 2016): I I63.133, I Table 15 s for TAVR/TAVI Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open femoral artery approach Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open axillary artery approach Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open iliac artery approach Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transaortic approach (eg, median sternotomy, mediastinotomy) Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with percutaneous peripheral arterial and venous cannulation (eg, femoral vessels) (List separately in addition to code for primary procedure) Published: October 24,

14 Table 15 s for TAVR/TAVI Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with open peripheral arterial and venous cannulation (eg, femoral, iliac, axillary vessels) (List separately in addition to code for primary procedure) Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with central arterial and venous cannulation (eg, aorta, right atrium, pulmonary artery) (List separately in addition to code for primary procedure) Table 16 ICD-10 Diagnosis Codes for VNS Services Diagnosis Code G Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus G Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, without status epilepticus G Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status epilepticus G Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus Table 17 ICD-10 s for VNS Services 01HY3MZ 01HY4MZ 0DH60MZ 0DH63MZ 0DH64MZ 00PE0MZ 00PE3MZ 00PE4MZ 00PEXMZ 01PY0MZ 01PY3MZ Insertion of neurostimulator lead into peripheral nerve, percutaneous approach Insertion of neurostimulator lead into peripheral nerve, percutaneous endoscopic approach Insertion of stimulator lead into stomach, open approach Insertion of stimulator lead into stomach, percutaneous approach Insertion of stimulator lead into stomach, percutaneous endoscopic approach Removal of neurostimulator lead from cranial nerve, open approach Removal of neurostimulator lead from cranial nerve, percutaneous approach Removal of neurostimulator lead from cranial nerve, percutaneous endoscopic approach Removal of neurostimulator lead from cranial nerve, external approach Removal of neurostimulator lead from peripheral nerve, open approach Removal of neurostimulator lead from peripheral nerve, percutaneous approach Published: October 24,

15 Table 17 ICD-10 s for VNS Services 01PY4MZ 01PYXMZ 0DP60MZ 0DP63MZ 0DP64MZ 0DPR0MZ 0DPR3MZ 0DPR4MZ 0JH60BZ 0JH63BZ 0JH70BZ 0JH73BZ 0JH80BZ 0JH83BZ 0JH60DZ 0JH63DZ 0JH70DZ 0JH73DZ 0JH80DZ 0JH83DZ 0JH60MZ 0JH63MZ 0JH70MZ 0JH73MZ Removal of neurostimulator lead from peripheral nerve, percutaneous endoscopic approach Removal of neurostimulator lead from peripheral nerve, external approach Removal of stimulator lead from stomach, open approach Removal of stimulator lead from stomach, percutaneous approach Removal of stimulator lead from stomach, percutaneous endoscopic approach Removal of stimulator lead from anal sphincter, open approach Removal of stimulator lead from anal sphincter, percutaneous approach Removal of stimulator lead from anal sphincter, percutaneous endoscopic approach Insertion of single array stimulator generator into chest subcutaneous tissue and fascia, open approach Insertion of single array stimulator generator into chest subcutaneous tissue and fascia, percutaneous approach Insertion of single array stimulator generator into back subcutaneous tissue and fascia, open approach Insertion of single array stimulator generator into back subcutaneous tissue and fascia, percutaneous approach Insertion of single array stimulator generator into abdomen subcutaneous tissue and fascia, open approach Insertion of single array stimulator generator into abdomen subcutaneous tissue and fascia, percutaneous approach Insertion of multiple array stimulator generator into chest subcutaneous tissue and fascia, open approach Insertion of multiple array stimulator generator into chest subcutaneous tissue and fascia, percutaneous approach Insertion of multiple array stimulator generator into back subcutaneous tissue and fascia, open approach Insertion of multiple array stimulator generator into back subcutaneous tissue and fascia, percutaneous approach Insertion of multiple array stimulator generator into abdomen subcutaneous tissue and fascia, open approach Insertion of multiple array stimulator generator into abdomen subcutaneous tissue and fascia, percutaneous approach Insertion of stimulator generator into chest subcutaneous tissue and fascia, open approach Insertion of stimulator generator into chest subcutaneous tissue and fascia, percutaneous approach Insertion of stimulator generator into back subcutaneous tissue and fascia, open approach Insertion of stimulator generator into back subcutaneous tissue and fascia, percutaneous approach Published: October 24,

16 Table 17 ICD-10 s for VNS Services 0JH80MZ 0JH83MZ 0JH60CZ 0JH63CZ 0JH70CZ 0JH73CZ 0JH80CZ 0JH83CZ 0JH60EZ 0JH63EZ 0JH70EZ 0JH73EZ 0JH80EZ 0JH83EZ 00WE0MZ 00WE3MZ 00WE4MZ 00WEXMZ Insertion of stimulator generator into abdomen subcutaneous tissue and fascia, open approach Insertion of stimulator generator into abdomen subcutaneous tissue and fascia, percutaneous approach Insertion of single array rechargeable stimulator generator into chest subcutaneous tissue and fascia, open approach Insertion of single array rechargeable stimulator generator into chest subcutaneous tissue and fascia, percutaneous approach Insertion of single array rechargeable stimulator generator into back subcutaneous tissue and fascia, open approach Insertion of single array rechargeable stimulator generator into back subcutaneous tissue and fascia, percutaneous approach Insertion of single array rechargeable stimulator generator into abdomen subcutaneous tissue and fascia, open approach Insertion of single array rechargeable stimulator generator into abdomen subcutaneous tissue and fascia, percutaneous approach Insertion of multiple array rechargeable stimulator generator into chest subcutaneous tissue and fascia, open approach Insertion of multiple array rechargeable stimulator generator into chest subcutaneous tissue and fascia, percutaneous approach Insertion of multiple array rechargeable stimulator generator into back subcutaneous tissue and fascia, open approach Insertion of multiple array rechargeable stimulator generator into back subcutaneous tissue and fascia, percutaneous approach Insertion of multiple array rechargeable stimulator generator into abdomen subcutaneous tissue and fascia, open approach Insertion of multiple array rechargeable stimulator generator into abdomen subcutaneous tissue and fascia, percutaneous approach Revision of neurostimulator lead in cranial nerve, open approach Revision of neurostimulator lead in cranial nerve, percutaneous approach Revision of neurostimulator lead in cranial nerve, percutaneous endoscopic approach Revision of neurostimulator lead in cranial nerve, external approach Published: October 24,

17 Table 18 CPT s for VNS Services Note: Prior authorization is required for codes with asterisk (*). Category Procedure Code Implantation 61885* Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling with connection to a single electrode array Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator 64553* Percutaneous implantation of neurostimulator electrode array; cranial nerve 64590* Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling Revision/Removal Revision or removal of cranial neurostimulator pulse generator or receiver Revision or replacement of cranial nerve (eg, vagus nerve) neurostimulator electrode array, including connection to existing pulse generator Removal of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator Revision or removal of peripheral neurostimulator electrode array Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver Table 19 s for Additional Reimbursement for the VNS Device and Components (Outpatient Only) Note: Codes with an asterisk (*) must include the U1 modifier when billed with VNS diagnosis codes. L8680 U1* L8681 L8685 L8686 U1* L8687 L8688 L8689 Implantable neurostimulator electrode, each, VNS only Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only Implantable neurostimulator pulse generator, single array, rechargeable, includes extension Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension, VNS only Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension External recharging system for battery (internal) for use with implantable neurostimulator, replacement only Published: October 24,

18 Table 20 Surgeon s for VNS Services Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling, with connection to a single electrode array Revision or removal of cranial neurostimulator pulse generator or receiver Percutaneous implantation of neurostimulator electrode array; cranial nerve Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator Revision or removal of peripheral neurostimulator electrode array Table 21 Neurologist s for VNS Services Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); simple or complex brain, spinal cord, or peripheral (ie, cranial nerve, peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, without reprogramming Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure) Published: October 24,

19 02WA0QZ, 02WA0RZ, 02WA3QZ, 02WA3RZ, 02WA4QZ, 02WA4RZ, 02WAXQZ, 02WAXRZ 02PA0RZ, 02PA3RZ, 02PA4RZ, 02PA0QZ, 02PA0RZ, 02PA3QZ, 02PA3RZ, 02PA4QZ, 02PA4RZ 02HA0RZ or 02HA4RZ along with 5A02116 or 5A HA0QZ, 02HA0RS, 02HA0RZ, 02HA3QZ, 02HA3RS, 02HA3RZ, 02HA4QZ, 02HA4RS, 02HA4RZ 02PA0NZ 02PA3NZ 02PA4NZ 02WA0NZ 02WA3NZ 02WA4NZ 02WAXNZ Table 22 ICD-10 s for VAD Services Repair of heart assist system Replacement of parts of an existing VAD Removal of heart assist system Implant of external heart assist system device (outside the body, but connected to heart) with external circulation and pump Includes: Open chest procedure for cannula attachments Implant of implantable heart assist system device directly connected to the heart and implanted in the upper left quadrant of peritoneal cavity. Includes: Axial flow heart assist system Diagonal pump heart assist system LVAD Pulsatile heart assist system Right ventricular assist device (RVAD) Rotary pump heart assist system Transportable, implantable heart assist system VAD, not otherwise specified Removal of intracardiac pacemaker from heart, open approach Removal of intracardiac pacemaker from heart, percutaneous approach Removal of intracardiac pacemaker from heart, percutaneous endoscopic approach Revision of intracardiac pacemaker in heart, open approach Revision of intracardiac pacemaker in heart, percutaneous approach Revision of intracardiac pacemaker in heart, percutaneous endoscopic approach Revision of intracardiac pacemaker in heart, external approach Table Revision History October 1, 2016, update: Added (effective October 1, 2016): 02PA0NZ, 02PA3NZ, 02PA4NZ, 02WA0NZ, 02WA3NZ, 02WA4NZ, 02WAXNZ Published: October 24,

20 Table 23 CPT s for VAD Services Insertion of ventricular assist device; extracorporeal, single ventricle Insertion of ventricular assist device; extracorporeal, biventricular Removal of ventricular assist device; extracorporeal, single ventricle Removal of ventricular assist device; extracorporeal, biventricular Insertion of ventricular assist device, implantable, intracorporeal, single ventricle Removal of ventricular assist device, implantable intracorporeal, single ventricle Insertion of ventricular assist device percutaneous including radiological supervision and interpretation; arterial access only Insertion of ventricular assist device, percutaneous including radiological supervision and interpretation; both arterial and venous access, with transeptal 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 Table 24 VAD Patient Supplies and Replacement Equipment s That Require Prior Authorization Q0480 Q0481 Q0482 Q0483 Q0484 Q0485 Q0486 Q0487 Q0488 Q0489 Q0490 Q0491 Q0492 Q0493 Drive for use with pneumatic VAD, replacement only Microprocessor control unit for use with electric VAD, replacement only Microprocessor control unit for use with electric/pneumatic combination VAD, replacement only Monitor/display module for use with electric VAD, replacement only Monitor/display module for use with electric or electric/pneumatic VAD, replacement only Monitor control cable for use with electric VAD, replacement only Monitor control cable for use with electric/pneumatic VAD, replacement only Leads (pneumatic/electrical) for use with any type electric/pneumatic VAD, replacement only Power pack base for use with electric VAD, replacement only Power pack base for use with electric/pneumatic VAD, replacement only Emergency power source for use with electric VAD, replacement only Emergency power source for use with electric/pneumatic VAD, replacement only Emergency power supply cable for use with electric VAD, replacement only Emergency power supply cable for use with electric/pneumatic VAD, replacement only Published: October 24,

21 Table 24 VAD Patient Supplies and Replacement Equipment s That Require Prior Authorization Q0494 Q0495 Emergency hand pump for use with electric or electric/pneumatic VAD, replacement only Battery/power pack charger for use with electric or electric/pneumatic VAD, replacement only Published: October 24,