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:C2

Policy #:MA00.010z

Description:

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.



RADIOLOGY NETWORK RULES AND LIMITED CIRCUMSTANCES

LIMITED CIRCUMSTANCES PROCEDURE CODE LIST



CARDIOLOGIST, PEDIATRIC CARDIOLOGIST, INTERVENTIONAL CARDIOLOGIST, CLINICAL CARDIAC ELECTROPHYSIOLOGIST & ADVANCED HEART FAILURE & TRANSPLANT SURGEON
(Office & Outpatient Hospital Places of Service)
Procedure Code
Date Code Added to the Policy
Date Code Removed from the Policy
78451
01-01-2010
78452
01-01-2010
78453
01-01-2010
78454
01-01-2010
78460
01-01-1988
12-31-2009
78461
01-01-1988
12-31-2009
78464
01-01-1988
12-31-2009
78465
01-01-1988
12-31-2009
78466
01-01-1988
78468
01-01-1988
78469
01-01-1988
78472
01-01-1988
78473
01-01-1992
78478
01-01-1992
12-31-2009
78480
01-01-1992
12-31-2009
78481
01-01-1988
78483
01-01-1992
78494
01-01-1999
78496
01-01-1999
93303
01-01-1997
93304
01-01-1997
93306
01-01-2009
93307
01-01-1982
93308
01-01-1982
93312
01-01-1989
93314
01-01-1993
93315
01-01-1997
93317
01-01-1997
93318
01-01-2001
93320
01-01-1982
93321
01-01-1990
93325
01-01-1990
93350
01-01-1990
93351
01-01-2009
93875
01-01-1992
12-31-2011

PEDIATRIC CARDIOLOGIST
(Office & Outpatient Hospital Places of Service)
Procedure Code
Date Code Added to the Policy
Date Code Removed from the Policy
76825
07-01-2009
76826
07-01-2009
76827
07-01-2009
76828
07-01-2009

OTORHINOLARYNGOLOGIST
(Office Place of Service)
Procedure Code
Date Code Added to the Policy
Date Code Removed from the Policy
70300
01-01-1984
70310
01-01-1984
70320
01-01-1984
70350
01-01-1984
70355
01-01-1984
70371
01-01-1988

OBSTETRICIAN-GYNECOLOGIST, MATERNAL FETAL, OBSTETRICS,
GYNECOLOGIST & REPRODUCTIVE ENDOCRINOLOGIST
(Office Place of Service)
Procedure Code
Date Code Added to the Policy
Date Code Removed from the Policy
G0202
01-01-2002
12/31/2017
G0204
01-01-2002
12/31/2017
G0206
01-01-2002
12/31/2017
S8055
01-01-2002
76801
01-01-2003
76802
01-01-2003
76805
01-01-1982
76810
01-01-1992
76811
01-01-2003
76812
01-01-2003
76813
01-01-2007
76814
01-01-2007
76815
01-01-1982
76816
01-01-1986
76817
01-01-2003
76818
01-01-1986
76819
01-01-2001
76820
01-01-2005
76821
01-01-2005
76825
01-01-1986
76826
01-01-1993
76827
01-01-1993
76828
01-01-1993
76830
01-01-1990
76831
01-01-1998
76856
01-01-1982
76857
01-01-1986
76999
01-01-1984
77051
01-01-2007
12-31-2016
77052
01-01-2007
12-31-2016
77055
01-01-2007
12-31-2016
77056
01-01-2007
12-31-2016
77057
01-01-2007
12-31-2016
77065
01-01-2017
77066
01-01-2017
77067
01-01-2017
93325
01-01-1990

Female Pelvic Reconstructive Surgery
(Office Place of Service)
Procedure Code
Date Code Added to the Policy
Date Code Removed from the Policy
76830
10-01-2015
76831
10-01-2015
76856
10-01-2015
76999
10-01-2015

Female Pelvic Reconstructive Surgery
(Office & Outpatient Hospital Places of Service)
Procedure Code
Date Code Added to the Policy
Date Code Removed from the Policy
76857
10-01-2015

Female Pelvic Reconstructive Surgery
( Outpatient Hospital Place of Service)
Procedure Code
Date Code Added to the Policy
Date Code Removed from the Policy
76830-26
10-01-2015
76831-26
10-01-2015
76856-26
10-01-2015
76857-26
10-01-2015

OBSTETRICIAN-GYNECOLOGIST, MATERNAL FETAL, OBSTETRICS,
GYNECOLOGIST & REPRODUCTIVE ENDOCRINOLOGIST
(Outpatient Hospital Place of Service)
Procedure Code
Date Code Added to the Policy
Date Code Removed from the Policy
76801-26
01-12-2011
76802-26
01-12-2011
76805-26
01-12-2011
76810-26
01-12-2011
76811-26
01-12-2011
76812-26
01-12-2011
76813-26
07-01-2011
76814-26
07-01-2011
76815-26
01-12-2011
76816-26
01-12-2011
76817-26
01-12-2011
76818-26
01-12-2011
76819-26
01-12-2011
76820-26
01-12-2011
76821-26
01-12-2011
76825-26
01-12-2011
76826-26
01-12-2011
76827-26
01-12-2011
76828-26
01-12-2011
76830-26
01-12-2011
76831-26
07-01-2011
76856-26
01-12-2011
76857-26
01-12-2011
93325-26
07-01-2011

HEMATOLOGY/ONCOLOGIST, MEDICAL ONCOLOGIST &
PEDIATRIC HEMATOLOGY/ONCOLOGIST
(Office Place of Service)
Procedure Code
Date Code Added to the Policy
Date Code Removed from the Policy
79005
01-01-2005

OPHTHALMOLOGY & PEDIATRIC OPHTHALMOLOGY
(Office Place of Service)
Procedure Code
Date Code Added to the Policy
Date Code Removed from the Policy
76510
01-01-2005
76511
01-01-1982
76512
01-01-1982
76513
01-01-1988
76514
01-01-2004
76516
01-01-1982
76519
01-01-1986
76529
01-01-1982

OPTOMETRY
(Office Place of Service)
Procedure Code
Date Code Added to the Policy
Date Code Removed from the Policy
76514
01-12-2011

ORAL SURGERY
(Office Place of Service)
Procedure Code
Date Code Added to the Policy
Date Code Removed from the Policy
70300
01-01-1984
70310
01-01-1984
70320
01-01-1984
70328
01-01-1984
70330
01-01-1984
70350
01-01-1984
70355
01-01-1984

ORTHOPEDIC SURGEON, HAND SURGEON &
SPORTS MEDICINE SPECIALIST
(Office Place of Service)
Procedure Code
Date Code Added to the Policy
Date Code Removed from the Policy
72010
01-01-1986
12/31/2015
72020
01-01-1984
72040
01-01-1984
72050
01-01-1984
72052
01-01-1984
72069
01-01-1991
12/31/2015
72070
01-01-1984
72072
01-01-1984
72074
01-01-1984
72080
01-01-1984
72081
01-01-2016
72082
01-01-2016
72083
01-01-2016
72084
01-01-2016
72090
01-01-1984
12/31/2015
72100
01-01-1984
72110
01-01-1984
72114
01-01-1984
72120
01-01-1984
72170
01-01-1984
72190
01-01-1984
72200
01-01-1984
72202
01-01-1984
72220
01-01-1985
73000
01-01-1984
73010
01-01-1984
73020
01-01-1984
73030
01-01-1984
73050
01-01-1984
73060
01-01-1984
73070
01-01-1984
73080
01-01-1984
73090
01-01-1984
73092
01-01-1984
73100
01-01-1984
73110
01-01-1984
73120
01-01-1984
73130
01-01-1984
73140
01-01-1984
73500
01-01-1984
12/31/2015
73501
01-01-2016
73502
01-01-2016
73503
01-01-2016
73510
01-01-1984
12/31/2015
73520
01-01-1984
12/31/2015
73521
01-01-2016
73522
01-01-2016
73523
01-01-2016
73540
01-01-1984
12/31/2015
73550
01-01-1984
12/31/2015
73551
01-01-2016
73552
01-01-2016
73560
01-01-1984
73562
01-01-1984
73564
01-01-1983
73565
01-01-1991
73590
01-01-1984
73592
01-01-1984
73600
01-01-1984
73610
01-01-1984
73620
01-01-1984
73630
01-01-1984
73650
01-01-1984
73660
01-01-1984
77071
01-01-2007

PODIATRIST
(Office Place of Service)
Procedure Code
Date Code Added to the Policy
Date Code Removed from the Policy
73600
01-01-1984
73610
01-01-1984
73620
01-01-1984
73630
01-01-1984
73650
01-01-1984
73660
01-01-1984

RHEUMATOLOGIST & PEDIATRIC RHEUMATOLOGIST
(Office Place of Service)
Procedure Code
Date Code Added to the Policy
Date Code Removed from the Policy
G0130
01-01-1999
77078
01-01-2007
77079
01-01-2007
12-31-2011
77080
01-01-2007
77081
01-01-2007
78351
01-01-1986

RADIATION ONCOLOGIST and THERAPIST
(Office & Outpatient Hospital Places of Service)
Procedure Code
Date Code Added to the Policy
Date Code Removed from the Policy
0394T
01-01-2016
0395T
01-01-2016
G6003
01-01-2015
G6004
01-01-2015
G6005
01-01-2015
G6006
01-01-2015
G6007
01-01-2015
G6008
01-01-2015
G6009
01-01-2015
G6010
01-01-2015
G6011
01-01-2015
G6012
01-01-2015
G6013
01-01-2015
G6014
01-01-2015
G6015
01-01-2015
G6016
01-01-2015
G6017
01-01-2015
Q3001
01-01-2001
77261
01-01-1984
77262
01-01-1984
77263
01-01-1984
77280
01-01-1984
77285
01-01-1984
77290
01-01-1984
77293
08-19-2019
77295
01-01-1994
77300
01-01-1984
77301
01-01-2002
77305
01-01-1984
12-31-2014
77306
01-01-2015
77307
01-01-2015
77310
01-01-1984
12-31-2014
77315
01-01-1984
12-31-2014
77316
01-01-2015
77317
01-01-2015
77318
01-01-2015
77321
01-01-1984
77326
01-01-1984
12-31-2014
77327
01-01-1984
12-31-2014
77328
01-01-1984
12-31-2014
77331
01-01-1984
77332
01-01-1984
77333
01-01-1984
77334
01-01-1984
77336
01-01-1984
77338
01-01-2010
77370
01-01-1984
77385
01-01-2015
77386
01-01-2015
77401
01-01-1991
77402
01-01-1991
77403
01-01-1991
77404
01-01-1991
12-31-2014
77406
01-01-1991
12-31-2014
77407
01-01-1991
77408
01-01-1991
12-31-2014
77409
01-01-1991
12-31-2014
77411
01-01-1991
12-31-2014
77412
01-01-1991
77413
01-01-1991
12-31-2014
77414
01-01-1991
12-31-2014
77416
01-01-1991
12-31-2014
77418
01-01-2002
12-31-2014
77422
01-01-2006
77423
01-01-2006
77427
01-01-2000
77431
01-01-1991
77432
01-01-1994
77470
01-01-1984
77499
01-01-1984
77600
01-01-1986
77605
01-01-1986
77610
01-01-1986
77615
01-01-1986
77620
01-01-1988
77750
01-01-1984
77761
01-01-1984
77762
01-01-1984
77763
01-01-1984
77767
01-01-2016
77768
01-01-2016
77770
01-01-2016
77771
01-01-2016
77772
01-01-2016
77776
01-01-1983
12/31/2015
77777
01-01-1984
12/31/2015
77778
01-01-1984
77781
01-01-1991
12-31-2008
77782
01-01-1991
12-31-2008
77783
01-01-1991
12-31-2008
77784
01-01-1991
12-31-2008
77785
01-01-2009
12/31/2015
77786
01-01-2009
12/31/2015
77787
01-01-2009
77789
01-01-1984
77790
01-01-1984
79005
01-01-2005

RADIATION ONCOLOGIST and THERAPIST
(Office Place of Service)
Procedure Code
Date Code Added to the Policy
Date Code Removed from the Policy
77417
01-01-1991

CARDIOLOGIST, PEDIATRIC CARDIOLOGIST, INTERVENTIONAL CARDIOLOGIST, CLINICAL CARDIAC ELECTROPHYSIOLOGIST, ADVANCED HEART FAILURE & TRANSPLANT SURGEON, SURGEON, PEDIATRIC SURGEON, NEUROLOGIST, PEDIATRIC NEUROLOGIST,
VASCULAR SURGEON & VASCULAR MEDICINE SPECIALIST, THORACIC SURGEON
(Office & Outpatient Hospital Places of Service)
Procedure Code
Date Code Added to the Policy
Date Code Removed from the Policy
93875
01-01-1992
12-31-2011
93880
01-01-1992
93882
01-01-1992
93886
01-01-1992
93888
01-01-1992
93890
01-01-2005
93892
01-01-2005
93893
01-01-2005
93922
01-01-1994
93923
01-01-1994
93924
01-01-1994
93925
01-01-1992
93926
01-01-1992
93930
01-01-1992
93931
01-01-1992
93965
01-01-1992
12-31-2016
93970
01-01-1992
93971
01-01-1992
93975
01-01-1992
93976
01-01-1992
93978
01-01-1992
93979
01-01-1992
93980
01-01-1993
93981
01-01-1993
93985
01-01-2020
93986
01-01-2020
93990
01-01-1995

VASCULAR and INTERVENTIONAL RADIOLOGIST
(Outpatient Hospital Places of Service)
Procedure Code
Date Code Added to the Policy
Date Code Removed from the Policy
93880
01-01-2016
93882
01-01-2016
93886
01-01-2016
93888
01-01-2016
93890
01-01-2016
93892
01-01-2016
93893
01-01-2016
93922
01-01-2016
93923
01-01-2016
93924
01-01-2016
93925
01-01-2016
93926
01-01-2016
93930
01-01-2016
93931
01-01-2016
93970
01-01-2016
93971
01-01-2016
93975
01-01-2016
93976
01-01-2016
93978
01-01-2016
93979
01-01-2016
93980
01-01-2016
93981
01-01-2016
93985
01-01-2020
93986
01-01-2020
93990
01-01-2016

SURGEON
(Office & Outpatient Hospital Places of Service)
Procedure Code
Date Code Added to the Policy
Date Code Removed from the Policy
76098
07-01-2009

UROLOGIST
(Office & Outpatient Hospital Places of Service)
Procedure
Code
Date Code Added to the Policy
Date Code Removed from the Policy
76857
01-01-1986
76873
01-01-2000
93980
01-01-1993
93981
01-01-1993

NUCLEAR MEDICINE SPECIALIST
(Office & Outpatient Hospital Places of Service)
Procedure Code
Date Code Added to the Policy
Date Code Removed from the Policy
G0219
01-01-2002
G0252
10-01-2002
S8085
01-01-2001
78000
01-01-1984
01-01-2013
78001
01-01-1984
01-01-2013
78003
01-01-1984
01-01-2013
78006
01-01-1984
01-01-2013
78007
01-01-1984
01-01-2013
78010
01-01-1984
01-01-2013
78011
01-01-1984
01-01-2013
78015
01-01-1984
78016
01-01-1984
78018
01-01-1984
78020
01-01-1999
78070
01-01-1989
78075
01-01-1984
78099
01-01-1984
78103
01-01-1984
78104
01-01-1984
78110
01-01-1984
78111
01-01-1984
78120
01-01-1984
78121
01-01-1984
78122
01-01-1987
78130
01-01-1984
78135
01-01-1984
78140
01-01-1984
78185
01-01-1984
78190
01-01-1991
78191
01-01-1984
78195
01-01-1984
78199
01-01-1984
78202
01-01-1984
78205
01-01-1988
01-01-2020
78206
01-01-1999
01-01-2020
78215
01-01-1984
78216
01-01-1984
78220
01-01-1984
12-31-2011
78223
01-01-1984
12-31-2011
78230
01-01-1984
78231
01-01-1984
78232
01-01-1984
78258
01-01-1987
78261
01-01-1984
78262
01-01-1984
78264
01-01-1984
78267
01-01-2000
78268
01-01-2000
78270
01-01-1985
78271
01-01-1985
78272
01-01-1984
78282
01-01-1985
78290
01-01-1984
78291
01-01-1985
78299
01-01-1984
78300
01-01-1984
78305
01-01-1984
78306
01-01-1984
78315
01-01-1987
78320
01-01-1988
01-01-2020
78350
01-01-1986
78351
01-01-1986
78399
01-01-1984
78414
01-01-1984
78428
01-01-1984
78429
01-01-2020
78430
01-01-2020
78431
01-01-2020
78432
01-01-2020
78433
01-01-2020
78434
01-01-2020
78445
01-01-1984
78456
01-01-2000
78457
01-01-1984
78458
01-01-1984
78460
01-01-1988
12-31-2009
78461
01-01-1988
12-31-2009
78464
01-01-1988
12-31-2009
78465
01-01-1988
12-31-2009
78466
01-01-1988
78468
01-01-1988
78469
01-01-1988
78472
01-01-1988
78473
01-01-1992
78478
01-01-1992
12-31-2009
78480
01-01-1992
12-31-2009
78481
01-01-1988
78483
01-01-1992
78491
01-01-1998
78492
01-01-1998
78494
01-01-1999
78496
01-01-1999
78499
01-01-1984
78580
01-01-1984
78585
01-01-1984
12-31-2011
78586
01-01-1984
12-31-2011
78587
01-01-1984
12-31-2011
78588
01-01-1999
12-31-2011
78591
01-01-1984
12-31-2011
78593
01-01-1984
12-31-2011
78594
01-01-1984
12-31-2011
78596
01-01-1991
12-31-2011
78599
01-01-1984
78600
01-01-1984
78601
01-01-1984
78605
01-01-1984
78606
01-01-1984
78607
01-01-1988
01-01-2020
78608
01-01-1994
78609
01-01-1994
78610
01-01-1984
78615
01-01-1984
12-31-2007
78630
01-01-1984
78645
01-01-1984
78647
01-01-1995
01-01-2020
78650
01-01-1984
78660
01-01-1984
78699
01-01-1984
78700
01-01-1984
78701
01-01-1984
78707
01-01-1984
78708
01-01-1998
78709
01-01-1998
78710
01-01-1988
01-01-2020
78725
01-01-1984
78730
01-01-1984
78740
01-01-1984
78761
01-01-1984
78799
01-01-1984
78800
01-01-1984
78801
01-01-1984
78802
01-01-1984
78804
01-01-2004
78805
01-01-1984
01-01-2020
78806
01-01-1984
01-01-2020
78807
01-01-1994
01-01-2020
78808
01-01-2009
78811
01-01-2005
78812
01-01-2005
78813
01-01-2005
78814
09-01-2015
78815
12-23-2011
78816
09-01-2015
78999
01-01-1984
79005
01-01-2005
79101
01-01-2005
79200
01-01-1984
79300
01-01-1984
79403
01-01-2004
79445
01-01-2005
79999
01-01-1982

INTERVENTIONAL RADIOLOGIST
(Office & Outpatient Hospital Places of Service)
Procedure Code
Date Code Added to the Policy
Date Code Removed from the Policy
75635
01-01-2001
78195
01-01-1984

INFECTIOUS DISEASE & GASTROENTEROLOGY
(Office & Outpatient Hospital Places of Service)
Procedure Code
Date Code Added to the Policy
Date Code Removed from the Policy
91200
04-15-2016




Version Effective Date: 05/18/2020
Version Issued Date: 05/18/2020
Version Reissued Date: N/A

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