Notification

PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services


Notification Issue Date: 02/14/2020



Policy Attachment

Attachment to Policy # MA00.010z


Attachment:D

Policy #:MA00.010z

Description:Physical Medicine & Rehabilitation Network Rules and Limited Circumstances

Title:PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.


PHYSICAL MEDICINE & REHABILITATION NETWORK RULES AND LIMITED CIRCUMSTANCES


NETWORK RULES PROCEDURE CODE LIST

Procedure Code
Date Code Added to the Policy
Date Code Removed from the Policy
G0515
01-01-2018
01-01-2020
G0281
04-01-2003
G0283
01-01-2003
S8950
01-01-2000
S9056
01-01-2000
S9090
01-01-2000
S9476
10-01-2003
97001
01-01-1998
12-31-2016
97002
01-01-1998
12-31-2016
97003
01-01-1998
12-31-2016
97004
01-01-1998
12-31-2016
97005
01-01-2002
12-31-2016
97006
01-01-2002
12-31-2016
97010
01-01-1984
97012
01-01-1984
97014
01-01-1983
97016
01-01-1984
97018
01-01-1984
97022
01-01-1984
97024
01-01-1983
97026
01-01-1984
97028
01-01-1984
97032
01-01-1995
97033
01-01-1995
97034
01-01-1995
97035
01-01-1995
97036
01-01-1995
97039
01-01-1984
97110
01-01-1984
97112
01-01-1984
97113
01-01-1995
97116
01-01-1984
97124
01-01-1984
97127
01-01-2018
01-01-2020
97129
01-01-2020
97130
01-01-2020
97139
01-01-1984
97140
01-01-1999
97150
01-01-1995
97161
01-01-2017
97162
01-01-2017
97163
01-01-2017
97164
01-01-2017
97165
01-01-2017
97166
01-01-2017
97167
01-01-2017
97168
01-01-2017
97169
01-01-2017
97170
01-01-2017
97171
01-01-2017
97172
01-01-2017
97530
01-01-1985
97532
01-01-2001
12-31-2017
97533
01-01-2001
97535
01-01-1996
97537
01-01-1996
97542
01-01-1996
97545
01-01-1993
97546
01-01-1993
97610
01-01-2014
97750
01-01-1995
97755
01-01-2004
97760
01-01-2006
97761
01-01-2006
97762
01-01-2006
12-31-2017
97763
01-01-2018
97799
01-01-1984


LIMITED CIRCUMSTANCES PROCEDURE CODE LIST
CHIROPRACTORS
(All Places of Service)
Procedure Code
Date Code Added to the Policy
Date Code Removed from the Policy
G0515
01-01-2018
01-01-2020
G0283
01-01-2003
S8950
01-01-2000
S9056
01-01-2000
S9090
01-01-2000
97010
01-01-1984
97012
01-01-1984
97014
01-01-1983
97016
01-01-1984
97018
01-01-1984
97022
01-01-1984
97024
01-01-1983
97026
01-01-1984
97028
01-01-1984
97032
01-01-1995
97033
01-01-1995
97034
01-01-1995
97035
01-01-1995
97036
01-01-1995
97039
01-01-1984
97110
01-01-1984
97112
01-01-1984
97113
01-01-1995
97116
01-01-1984
97124
01-01-1984
97127
01-01-2018
01-01-2020
97129
01-01-2020
97130
01-01-2020
97139
01-01-1984
97140
01-01-1999
97150
01-01-1995
97530
01-01-1985
97532
01-01-2001
12-31-2017
97533
01-01-2001
97535
01-01-1996
97537
01-01-1996
97542
01-01-1996
97545
01-01-1993
97546
01-01-1993
97750
01-01-1995
97799
01-01-1984


OCCUPATIONAL THERAPIST
(All Places of Service)
Procedure Code
Date Code Added to the Policy
Date Code Removed from the Policy
G0515
01-01-2018
01-01-2020
G0281
04-01-2003
G0283
01-01-2003
S8950
01-01-2000
S9476
10-01-2003
97001
01-01-1998
12-31-2016
97002
01-01-1998
12-31-2016
97003
01-01-1998
12-31-2016
97004
01-01-1998
12-31-2016
97010
01-01-1984
97012
01-01-1984
97014
01-01-1983
97016
01-01-1984
97018
01-01-1984
97022
01-01-1984
97024
01-01-1983
97026
01-01-1984
97028
01-01-1984
97032
01-01-1995
97033
01-01-1995
97034
01-01-1995
97035
01-01-1995
97036
01-01-1995
97039
01-01-1984
97110
01-01-1984
97112
01-01-1984
97113
01-01-1995
97116
01-01-1984
97124
01-01-1984
97127
01-01-2018
01-01-2020
97129
01-01-2020
97130
01-01-2020
97139
01-01-1984
97140
01-01-1999
97150
01-01-1995
97161
01-01-2017
97162
01-01-2017
97163
01-01-2017
97164
01-01-2017
97165
01-01-2017
97166
01-01-2017
97167
01-01-2017
97168
01-01-2017
97530
01-01-1985
97532
01-01-2001
12-31-2017
97533
01-01-2001
97535
01-01-1996
97537
01-01-1996
97542
01-01-1996
97545
01-01-1993
97546
01-01-1993
97750
01-01-1995
97755
01-01-2004
97760
01-01-2006
97761
01-01-2006
97762
01-01-2006
12-31-2017
97763
01-01-2018
97799
01-01-1984


OPTOMETRIST FOR LOW VISION SERVICES
(Office & Outpatient Hospital Places of Service)
Procedure Code
ICD-10 Codes
Date Code Added to the Policy
Date Code Removed from the Policy
97165
H53.411, H53.412, H53.413, H53.419, H53.421, H53.422, H53.423, H53.429, H54.0X33, H54.0X34, H54.0X35, H54.0X43, H54.0X44, H54.0X45, H54.0X53, H54.0X54, H54.0X55, H54.10, H54.1131, H54.1132, H54.1141, H54.1142, H54.1151, H54.1152, H54.1213, H54.1214, H54.1215, H54.1223, H54.1224, H54.1225, H54.2X11, H54.2X12, H54.2X21, H54.2X22, H54.3, H54.40, H54.413A, H54.414A, H54.415A, H54.42A3, H54.42A4, H54.42A5, H54.50, H54.511A, H54.512A, H54.52A1, H54.52A2, H54.60, H54.61, H54.62, H54.7, H54.8
01-01-2017
97166
H53.411, H53.412, H53.413, H53.419, H53.421, H53.422, H53.423, H53.429, H54.0X33, H54.0X34, H54.0X35, H54.0X43, H54.0X44, H54.0X45, H54.0X53, H54.0X54, H54.0X55, H54.10, H54.1131, H54.1132, H54.1141, H54.1142, H54.1151, H54.1152, H54.1213, H54.1214, H54.1215, H54.1223, H54.1224, H54.1225, H54.2X11, H54.2X12, H54.2X21, H54.2X22, H54.3, H54.40, H54.413A, H54.414A, H54.415A, H54.42A3, H54.42A4, H54.42A5, H54.50, H54.511A, H54.512A, H54.52A1, H54.52A2, H54.60, H54.61, H54.62, H54.7, H54.8
01-01-2017
97167
H53.411, H53.412, H53.413, H53.419, H53.421, H53.422, H53.423, H53.429, H54.0X33, H54.0X34, H54.0X35, H54.0X43, H54.0X44, H54.0X45, H54.0X53, H54.0X54, H54.0X55, H54.10, H54.1131, H54.1132, H54.1141, H54.1142, H54.1151, H54.1152, H54.1213, H54.1214, H54.1215, H54.1223, H54.1224, H54.1225, H54.2X11, H54.2X12, H54.2X21, H54.2X22, H54.3, H54.40, H54.413A, H54.414A, H54.415A, H54.42A3, H54.42A4, H54.42A5, H54.50, H54.511A, H54.512A, H54.52A1, H54.52A2, H54.60, H54.61, H54.62, H54.7, H54.8
01-01-2017
97168
H53.411, H53.412, H53.413, H53.419, H53.421, H53.422, H53.423, H53.429, H54.0X33, H54.0X34, H54.0X35, H54.0X43, H54.0X44, H54.0X45, H54.0X53, H54.0X54, H54.0X55, H54.10, H54.1131, H54.1132, H54.1141, H54.1142, H54.1151, H54.1152, H54.1213, H54.1214, H54.1215, H54.1223, H54.1224, H54.1225, H54.2X11, H54.2X12, H54.2X21, H54.2X22, H54.3, H54.40, H54.413A, H54.414A, H54.415A, H54.42A3, H54.42A4, H54.42A5, H54.50, H54.511A, H54.512A, H54.52A1, H54.52A2, H54.60, H54.61, H54.62, H54.7, H54.8
01-01-2017
97535
H53.411, H53.412, H53.413, H53.419, H53.421, H53.422, H53.423, H53.429, H54.0X33, H54.0X34, H54.0X35, H54.0X43, H54.0X44, H54.0X45, H54.0X53, H54.0X54, H54.0X55, H54.10, H54.1131, H54.1132, H54.1141, H54.1142, H54.1151, H54.1152, H54.1213, H54.1214, H54.1215, H54.1223, H54.1224, H54.1225, H54.2X11, H54.2X12, H54.2X21, H54.2X22, H54.3, H54.40, H54.413A, H54.414A, H54.415A, H54.42A3, H54.42A4, H54.42A5, H54.50, H54.511A, H54.512A, H54.52A1, H54.52A2, H54.60, H54.61, H54.62, H54.7, H54.8
01-01-2017


PHYSIATRIST
(Office & Outpatient Hospital Places of Service)
Procedure Code
Date Code Added to the Policy
Date Code Removed from the Policy
97110
07/01/2009
97140
07/01/2009
97530
07/01/2009


SPEECH THERAPIST SPECIALIST
(Office & Outpatient Hospital Places of Service)
Procedure Code
Date Code Added to the Policy
Date Code Removed from the Policy
G0515
01-01-2018
01-01-2020
97532
01-01-2001
12-31-2017


SPORTS MEDICINE SPECIALIST
(Office & Outpatient Hospital Places of Service)
Procedure Code
Date Code Added to the Policy
Date Code Removed from the Policy
97760
07-01-2011
Version Effective Date: 05/18/2020
Version Issued Date: 05/18/2020
Version Reissued Date: N/A

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