|  | | 08.00.62l | Abatacept(Orencia®)forInjectionforIntravenousUse08.00.62l | Pharmacy (08) | Abatacept (Orencia®) for Injection for Intravenous Use | 394267e0-a5ab-4a65-b114-71b24fc55bd1 | 2725 | Abatacept (Orencia®) for Injection for Intravenous Use | 08.00.62 | {"2726": {"Id":2726,"MPAttachmentLetter":"A","Title":"ICD-10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":4966,"PolicyAttachmentPageName":"ab7d6c23-9f6b-4151-90ee-56ece05da01a"},} |
|  | | 12.00.01f | Acupuncture(Independence)12.00.01f | Miscellaneous (12) | Acupuncture (Independence) | 9b891878-088a-46b3-87eb-d2032e21e161 | 3177 | Acupuncture (Independence) | 12.00.01 | {"3178": {"Id":3178,"MPAttachmentLetter":"A","Title":"ICD-10 CM Codes Eligible to be Reported for Acupuncture","MPPolicyAttachmentInternalSourceId":5410,"PolicyAttachmentPageName":"0c7269c3-4107-4e68-a3d6-0913e0b02dcd"},} |
| | | 12.04.04a | AcuteCareFacilityInpatientTransfers12.04.04a | Miscellaneous (12) | Acute Care Facility Inpatient Transfers | a26ef448-30db-43ac-94c2-e6d4b2be4b3a | 3272 | Acute Care Facility Inpatient Transfers | 12.04.04 | |
| | | 08.01.11f | Ado-TrastuzumabEmtansine(Kadcyla®)08.01.11f | Pharmacy (08) | Ado-Trastuzumab Emtansine (Kadcyla®) | b1b70e6b-f0a4-4e8d-a402-c16710ec6422 | 2880 | Ado-Trastuzumab Emtansine (Kadcyla®) | 08.01.11 | {"2881": {"Id":2881,"MPAttachmentLetter":"A","Title":"ICD-10-CM Codes and Narratives","MPPolicyAttachmentInternalSourceId":4967,"PolicyAttachmentPageName":"93337778-48af-4f3e-8a67-96c5f917cbb1"},} |
| | | 08.00.69b | Agalsidase beta (Fabrazyme®) | Pharmacy (08) | Agalsidase beta (Fabrazyme®) | 85256AA800623D7A852585420071736C | 2031 | Agalsidase beta (Fabrazyme®) | 08.00.69 | |
| | | 12.04.03c | AirAmbulanceServices12.04.03c | Miscellaneous (12) | Air Ambulance Services | 225d3101-03b1-4bcf-bbb9-96b94e93d897 | 3340 | Air Ambulance Services | 12.04.03 | |
| | | 08.01.22d | Alemtuzumab(Lemtrada®)08.01.22d | Pharmacy (08) | Alemtuzumab (Lemtrada®) | 73aa91d4-6dd1-4f04-aca2-d73e96227091 | 3349 | Alemtuzumab (Lemtrada®) | 08.01.22 | |
| | | 08.00.72h | Alglucosidase alfa (e.g., Lumizyme®) | Pharmacy (08) | Alglucosidase alfa (e.g., Lumizyme®) | 85256AA800623D7A8525854200710D18 | 2032 | Alglucosidase alfa (e.g., Lumizyme®) | 08.00.72 | |
| | | 07.00.21j | AllergyImmunotherapy07.00.21j | Medicine (07) | Allergy Immunotherapy | ed39b1c3-6d7a-468f-a34f-d38ae5a9c7b9 | 3158 | Allergy Immunotherapy | 07.00.21 | |
| | | 06.02.29d | AlloMap™MolecularExpressionTestingforHeartTransplantRejection(IndependenceAdministrators)06.02.29d | Pathology and Laboratory (06) | AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (Independence Administrators) | 50885de3-59ab-43a6-9222-a0a4e00c9908 | 3169 | AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (Independence Administrators) | 06.02.29 | |
| | | 08.00.91e | Alpha1-AntitrypsinTherapy(e.g.,Prolastin-C®,AralastNP®,Glassia®,Zemaira®)08.00.91e | Pharmacy (08) | Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP®, Glassia®, Zemaira®) | 5382f61c-2acd-4417-831b-1daf8729bdbc | 2892 | Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP®, Glassia®, Zemaira®) | 08.00.91 | |
| | | 00.01.52m | AlwaysBundledProcedureCodes00.01.52m | Administrative (00) | Always Bundled Procedure Codes | 19004006-80b1-4963-b83b-5c9d41abc3db | 3422 | Always Bundled Procedure Codes | 00.01.52 | {"3423": {"Id":3423,"MPAttachmentLetter":"A","Title":"Always Bundled Procedures (Indicator B)","MPPolicyAttachmentInternalSourceId":5646,"PolicyAttachmentPageName":"c447f051-ffcf-47b4-a28a-f5b5fb7ff047"},"3424": {"Id":3424,"MPAttachmentLetter":"B","Title":"Procedures/Services Not Eligible for Separate Reimbursement","MPPolicyAttachmentInternalSourceId":5647,"PolicyAttachmentPageName":"631e047f-217b-44f9-af38-00d5a5ee4ff1"},"3425": {"Id":3425,"MPAttachmentLetter":"C","Title":"Procedures/Services Not Eligible for Reimbursement","MPPolicyAttachmentInternalSourceId":5648,"PolicyAttachmentPageName":"fb5348d6-0391-4113-922e-324b94e6812e"},} |
| | | 07.02.09g | AmbulatoryBloodPressureMonitoring(ABPM)andHomeBloodPressureMonitoring(HBPM)Devices07.02.09g | Medicine (07) | Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices | fadd0242-f323-49fe-8ca7-2112b67a09c4 | 3006 | Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices | 07.02.09 | |
| | | 07.02.21g | AmbulatoryElectrocardiography(AECG)MonitoringandMobileCardiacOutpatientTelemetry(MCOT)Monitoring07.02.21g | Medicine (07) | Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring | 84bdd818-7e84-4d73-8f49-5fbe8993bab5 | 3390 | Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring | 07.02.21 | |
| | | 05.00.39q | Ankle-Foot/Knee-Ankle-FootOrthoses05.00.39q | DME (05) | Ankle-Foot/Knee-Ankle-Foot Orthoses | 4eb27cec-77a2-41a0-868f-cfbaa9b1d9a6 | 3079 | Ankle-Foot/Knee-Ankle-Foot Orthoses | 05.00.39 | {"3080": {"Id":3080,"MPAttachmentLetter":"A","Title":"HCPCS Codes","MPPolicyAttachmentInternalSourceId":5396,"PolicyAttachmentPageName":"944d1d3e-aa40-4b5c-b972-0effc02570ce"},} |
| | | 06.03.04n | ApheresisTherapy06.03.04n | Pathology and Laboratory (06) | Apheresis Therapy | 36aee0bb-d271-4e94-8256-eafdfce45397 | 2774 | Apheresis Therapy | 06.03.04 | |
| | | 11.08.05g | ApplicationandRemovalofTattoos11.08.05g | Surgery (11) | Application and Removal of Tattoos | 877c1fd6-b369-4fc9-8864-59f82b761dc2 | 2642 | Application and Removal of Tattoos | 11.08.05 | |
| | | 08.01.41c | Aprepitant(Cinvanti™),FosaprepitantDimeglumine(Emend®),Granisetron(Sustol®),andRolapitant(Varubi®)08.01.41c | Pharmacy (08) | Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®) | cc0cf1c4-3d26-463a-a21f-08aa066cf248 | 3456 | Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®) | 08.01.41 | {"3457": {"Id":3457,"MPAttachmentLetter":"A","Title":"Risk of Emesis Without Prophylaxis: Intravenous and Oral Antineoplastic Agents","MPPolicyAttachmentInternalSourceId":5660,"PolicyAttachmentPageName":"7eb7a411-ced7-42e9-aa86-ada2c7ac4697"},} |
| | | 11.05.16i | AqueousShunts,Microstents,Viscocanalostomy,andCanaloplastyfortheTreatmentofGlaucoma11.05.16i | Surgery (11) | Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma | f4ad855b-1bf8-4318-9dfb-398610d6aa5d | 3312 | Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma | 11.05.16 | {"3313": {"Id":3313,"MPAttachmentLetter":"A","Title":"ICD-10 codes","MPPolicyAttachmentInternalSourceId":5521,"PolicyAttachmentPageName":"ce13f43a-df56-4a6c-b295-d70cd335fca5"},} |
| | | 11.14.19p | ArtificialIntervertebralCervicalDiscInsertion(IndependenceAdministrators)11.14.19p | Surgery (11) | Artificial Intervertebral Cervical Disc Insertion (Independence Administrators) | e09699f1-6205-4c4f-b9b5-07035eacc229 | 2917 | Artificial Intervertebral Cervical Disc Insertion (Independence Administrators) | 11.14.19 | |
| | | 11.15.31 | ArtificialIntervertebralLumbarDiscInsertion11.15.31 | Surgery (11) | Artificial Intervertebral Lumbar Disc Insertion | a123b843-9dc4-4281-9614-0931a6c966d2 | 2916 | Artificial Intervertebral Lumbar Disc Insertion | 11.15.31 | |
| | | 08.01.35c | AsparaginaseErwiniaChrysanthemi(Erwinaze®)08.01.35c | Pharmacy (08) | Asparaginase Erwinia Chrysanthemi (Erwinaze®) | 71445744-0bb7-4616-86d4-6c1a231df3c6 | 2983 | Asparaginase Erwinia Chrysanthemi (Erwinaze®) | 08.01.35 | |
| | | 06.02.27l | AssaysofGeneticExpressioninTumorTissueforBreastCancerPrognosis(IndependenceAdministrators)06.02.27l | Pathology and Laboratory (06) | Assays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis (Independence Administrators) | 9181dc9f-7943-4cc9-a854-5ec1c5357691 | 3168 | Assays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis (Independence Administrators) | 06.02.27 | |
| | | 07.10.06i | AssistedReproductiveTechnologyforInfertilityandOocyteCryopreservation07.10.06i | Medicine (07) | Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation | 964f2d08-cb46-4737-8a74-39b81deb6f6a | 2824 | Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation | 07.10.06 | |
| | | 08.01.69 | Atezolizumab(Tecentriq®)08.01.69 | Pharmacy (08) | Atezolizumab (Tecentriq®) | ae81a8ad-97c0-4dfd-8ce9-fe2532d6a43a | 2469 | Atezolizumab (Tecentriq®) | 08.01.69 | {"2470": {"Id":2470,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":4723,"PolicyAttachmentPageName":"ff1a9148-d750-4345-aece-2735ddef2f1b"},} |
| | | 11.14.06j | AutologousChondrocyteImplantation(ACI)andOtherCell-basedTreatmentsofFocalArticularCartilageLesions(IndependenceAdministrators)11.14.06j | Surgery (11) | Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions (Independence Administrators) | 70726fcf-404b-4ff9-9280-ac452ac48c19 | 2932 | Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions (Independence Administrators) | 11.14.06 | |
| | | 05.00.29l | Automatic External Cardioverter Defibrillators (Wearable and Nonwearable) | DME (05) | Automatic External Cardioverter Defibrillators (Wearable and Nonwearable) | A0450B1CECA727FF852585AB00533565 | 2397 | Automatic External Cardioverter Defibrillators (Wearable and Nonwearable) | 05.00.29 | {"2405": {"Id":2405,"MPAttachmentLetter":"B","Title":"ICD-10 codes used to represent the Nonwearable Automatic External Defibrillator (AED):","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"DE272CF959A83D46852585AB00533585"},"2406": {"Id":2406,"MPAttachmentLetter":"A","Title":"ICD-10 Codes used to represent the Wearable Automatic External Defibrillator (AED):","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"5080E542121FA54B852585AB0053357F"},} |
| | | 07.03.23d | AutonomicNervousSystemTesting07.03.23d | Medicine (07) | Autonomic Nervous System Testing | 4efbfdc0-b5ec-43df-9116-dd957dace7cf | 3326 | Autonomic Nervous System Testing | 07.03.23 | |
| | | 08.01.64 | Avelumab(Bavencio®)08.01.64 | Pharmacy (08) | Avelumab (Bavencio®) | 7e0e42f8-cf2c-4eb6-a9d8-4b172c1df27a | 2451 | Avelumab (Bavencio®) | 08.01.64 | {"2452": {"Id":2452,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":2486,"PolicyAttachmentPageName":"924afd68-e6b3-4c07-98e4-722d7e259554"},} |
| | | 11.16.06j | BalloonCatheterDilationofSinusOstiaforTreatmentofChronicRhinosinusitis11.16.06j | Surgery (11) | Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis | b4850e37-c01a-4c04-aef2-7d9fed86e706 | 2695 | Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis | 11.16.06 | |
| | | 11.03.02t | BariatricSurgery11.03.02t | Surgery (11) | Bariatric Surgery | e2e22104-ada2-4d84-9c71-c600f1ea170e | 2791 | Bariatric Surgery | 11.03.02 | {"2792": {"Id":2792,"MPAttachmentLetter":"A","Title":"Body Mass Index (BMI) Charts","MPPolicyAttachmentInternalSourceId":4907,"PolicyAttachmentPageName":"292a20ba-ec48-442c-a624-40100880cb31"},"2793": {"Id":2793,"MPAttachmentLetter":"B","Title":"Tanner Staging System Criteria for Adolescents","MPPolicyAttachmentInternalSourceId":4908,"PolicyAttachmentPageName":"1b6da816-a2b6-4583-807a-5430c89f8392"},"2794": {"Id":2794,"MPAttachmentLetter":"C","Title":"ICD-10-CM codes","MPPolicyAttachmentInternalSourceId":4909,"PolicyAttachmentPageName":"b9184a36-7491-498e-aac9-ed1933abf92b"},} |
| | | 08.01.70b | Belantamabmafodotin-blmf(Blenrep)08.01.70b | Pharmacy (08) | Belantamab mafodotin-blmf (Blenrep) | bde34a1a-c1f2-4778-b78a-72050d24e484 | 3176 | Belantamab mafodotin-blmf (Blenrep) | 08.01.70 | |
| | | 08.00.99d | Belimumab(Benlysta®)forIntravenousUse08.00.99d | Pharmacy (08) | Belimumab (Benlysta®) for Intravenous Use | a538b471-570c-403b-9114-cc764e9fba6a | 3036 | Belimumab (Benlysta®) for Intravenous Use | 08.00.99 | |
| | | 08.00.66o | Bevacizumab(Avastin®)andRelatedBiosimilarsForOncologicUse08.00.66o | Pharmacy (08) | Bevacizumab (Avastin®) and Related Biosimilars For Oncologic Use | 189b1146-8951-44d1-8e41-f3eb252918ec | 2984 | Bevacizumab (Avastin®) and Related Biosimilars For Oncologic Use | 08.00.66 | {"2985": {"Id":2985,"MPAttachmentLetter":"A","Title":"Dosing and Frequency Requirements","MPPolicyAttachmentInternalSourceId":5036,"PolicyAttachmentPageName":"98bfbb87-d5a2-44b4-a5ef-b1b180d98102"},} |
| | | 00.10.39n | BillingforProfessionalOffice-BasedServicesPerformedinanOutpatientOffice-BasedSettingLocatedwithinaFacilityoronaFacilityCampus00.10.39n | Administrative (00) | Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus | 44d1f93e-e431-4e85-a65f-99ebd167ae49 | 2901 | Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus | 00.10.39 | {"2902": {"Id":2902,"MPAttachmentLetter":"A","Title":"Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus","MPPolicyAttachmentInternalSourceId":5191,"PolicyAttachmentPageName":"4d997fc7-79b5-47d4-b004-59a1ff458993"},} |
| | | 00.10.38a | BillingRequirementsforMultipleBirthsforProfessionalProviders00.10.38a | Administrative (00) | Billing Requirements for Multiple Births for Professional Providers | 7467b7be-328a-4664-89ab-13b4c0859839 | 3051 | Billing Requirements for Multiple Births for Professional Providers | 00.10.38 | {"3052": {"Id":3052,"MPAttachmentLetter":"A","Title":"MULTIPLE BIRTH CODING SCENARIOS FOR DELIVERY OF TWINS WHEN ROUTINE OBSTETRIC (GLOBALE MATERNITY/OBSTETRIC [OB]) CARE WAS PROVIDED","MPPolicyAttachmentInternalSourceId":5340,"PolicyAttachmentPageName":"d157b661-7eea-46ea-ab0f-b6ec2bd15a87"},"3053": {"Id":3053,"MPAttachmentLetter":"B","Title":"MULTIPLE BIRTH CODING SCENARIOS FOR DELIVERY OF TWINS WHEN ANETEPARTUM CARE IS NOT PROVIDED","MPPolicyAttachmentInternalSourceId":5341,"PolicyAttachmentPageName":"5d22c25e-12c7-42e4-a127-e50b59895309"},"3054": {"Id":3054,"MPAttachmentLetter":"C","Title":"CODING SCENARIOS FOR REPORTING HIGH-ORDER MULTIPLE (TRIPLETS, QUADRUPLETS, ETC) BIRTHS WHEN ROUTINE OBSTETRIC (GLOBAL MATERNITY/OBSTETRIC [OB]) CARE WAS PROVIDED","MPPolicyAttachmentInternalSourceId":5342,"PolicyAttachmentPageName":"d0a0d176-67d6-4d41-9e52-2cbec1ebff3d"},"3055": {"Id":3055,"MPAttachmentLetter":"D","Title":"MULTIPLE BIRTH CODING SCENARIOS FOR DELIVERY OF HIGH-ORDER MULTIPLES WHEN ANTEPARTUM CARE IS NOT PROVIDED","MPPolicyAttachmentInternalSourceId":5343,"PolicyAttachmentPageName":"74d58125-3d75-4d7b-8d89-cbaebd03cc03"},} |
| | | 07.00.01j | BiofeedbackTherapy07.00.01j | Medicine (07) | Biofeedback Therapy | 81ada7d5-27d5-4c0f-bc59-c401eefc836f | 2653 | Biofeedback Therapy | 07.00.01 | |
| | | 07.06.03b | BioimpedencefortheDetectionofLymphedema07.06.03b | Medicine (07) | Bioimpedence for the Detection of Lymphedema | 6b56ce1e-6818-41bb-9061-330aebb8ecf5 | 3321 | Bioimpedence for the Detection of Lymphedema | 07.06.03 | |
| | | 11.05.02j | Blepharoplasty,RepairofBlepharoptosis,RepairofBrowPtosis,andCanthoplasty/Canthopexy11.05.02j | Surgery (11) | Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy | 05af1ff1-9439-4274-90cd-c00835000c0e | 2975 | Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy | 11.05.02 | {"2976": {"Id":2976,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":5006,"PolicyAttachmentPageName":"4cca31c1-c0b9-45fc-bfdb-e773e1b7116a"},} |
| | | 08.01.21d | Blinatumomab(Blincyto®)08.01.21d | Pharmacy (08) | Blinatumomab (Blincyto®) | 2d06cc9f-7fee-4974-8d3b-5354317cf365 | 3287 | Blinatumomab (Blincyto®) | 08.01.21 | |
| | | 11.01.06e | Bone-Anchored(Osseointegrated)HearingAidsandImplantableMiddleEarHearingAids11.01.06e | Surgery (11) | Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids | 92e12e9d-2a7b-499b-bbe2-cbb276bc17ba | 2702 | Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids | 11.01.06 | |
| | | 09.00.04k | BoneMineralDensity(BMD)Testing09.00.04k | Radiology (09) | Bone Mineral Density (BMD) Testing | 76a3c9fb-280f-49e8-b8ce-7d213e0ec49f | 3239 | Bone Mineral Density (BMD) Testing | 09.00.04 | |
| | | 08.00.73m | Bortezomib(BortezomibforInjection,Velcade®)08.00.73m | Pharmacy (08) | Bortezomib (Bortezomib for Injection, Velcade®) | baa812b2-43e6-4cff-82b5-9592a674f59e | 3150 | Bortezomib (Bortezomib for Injection, Velcade®) | 08.00.73 | |
| | | 08.00.26x | BotulinumToxinAgents08.00.26x | Pharmacy (08) | Botulinum Toxin Agents | f3a2fbd3-38cb-431f-8734-441b29bf1dfa | 3171 | Botulinum Toxin Agents | 08.00.26 | {"3172": {"Id":3172,"MPAttachmentLetter":"A","Title":"ICD-10 Diagnosis Codes","MPPolicyAttachmentInternalSourceId":5156,"PolicyAttachmentPageName":"b99590fc-80da-417b-b8a5-4da094ad7d28"},} |
| | | 09.00.10z | BrachytherapyandAcceleratedWholeBreastIrradiationusingThree-DimensionalConformationRadiationTherapy09.00.10z | Radiology (09) | Brachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation Therapy | 4cb3894b-2c2b-4737-a0c4-1ba6c6a65167 | 3041 | Brachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation Therapy | 09.00.10 | |
| | | 05.00.76d | BreastPumps05.00.76d | DME (05) | Breast Pumps | 28248bd2-5b32-49ca-87b0-e1cfda1abbc7 | 2720 | Breast Pumps | 05.00.76 | |
| | | 08.01.13e | BrentuximabVedotin(Adcetris®)08.01.13e | Pharmacy (08) | Brentuximab Vedotin (Adcetris®) | 8b0960f6-d97d-43d8-b419-d94c9860ce8a | 3009 | Brentuximab Vedotin (Adcetris®) | 08.01.13 | {"3010": {"Id":3010,"MPAttachmentLetter":"A","Title":"ICD CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":5096,"PolicyAttachmentPageName":"b33e246d-9714-4e3c-91c0-e51c66859b8e"},} |
| | | 11.16.07b | Bronchial Thermoplasty | Surgery (11) | Bronchial Thermoplasty | 85256AA800623D7A852585A4005899AC | 1791 | Bronchial Thermoplasty | 11.16.07 | |
| | | 08.01.49b | Burosumab-twza(Crysvita®)08.01.49b | Pharmacy (08) | Burosumab-twza (Crysvita®) | d7f202d9-ab28-404f-adf1-0798651bfeb6 | 3034 | Burosumab-twza (Crysvita®) | 08.01.49 | |
| | | 08.01.51a | Canakinumab(Ilaris®)08.01.51a | Miscellaneous (12) | Canakinumab (Ilaris®) | 38d30b81-d6e8-498c-bccd-3c3f2baa02a4 | 3000 | Canakinumab (Ilaris®) | 08.01.51 | |
| | | 10.01.01n | CardiacRehabilitation(CR)andIntensiveCardiacRehabilitation(ICR)Programs10.01.01n | Rehabilitation Services (10) | Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs | 4f1e0439-21a8-49d2-bc90-7a39d70677e5 | 2717 | Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs | 10.01.01 | {"2718": {"Id":2718,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":4998,"PolicyAttachmentPageName":"48fe8723-3060-4b73-8f7f-30d46dc317cf"},} |
| | | 00.01.59h | CareManagementandCarePlanningServices00.01.59h | Administrative (00) | Care Management and Care Planning Services | 8e339ceb-45a8-4a58-a802-6e0d86f524a5 | 2893 | Care Management and Care Planning Services | 00.01.59 | |
| | | 08.01.05g | Carfilzomib(Kyprolis®)08.01.05g | Pharmacy (08) | Carfilzomib (Kyprolis®) | 26a9c1aa-7bed-41e2-a468-178e8e009f8c | 2645 | Carfilzomib (Kyprolis®) | 08.01.05 | |
| | | 00.10.15d | CastandSplintApplicationsandAssociatedSupplies00.10.15d | Administrative (00) | Cast and Splint Applications and Associated Supplies | 9a58b2c2-ac51-4f36-b633-45311f346cea | 2782 | Cast and Splint Applications and Associated Supplies | 00.10.15 | {"2783": {"Id":2783,"MPAttachmentLetter":"A","Title":"Procedure Codes Related to Cast and Splint Applications and Associated Supplies","MPPolicyAttachmentInternalSourceId":4979,"PolicyAttachmentPageName":"0e216c08-2117-49fb-87c3-6ff39b233cd3"},} |
| | | 11.01.07e | CataractSurgery11.01.07e | Surgery (11) | Cataract Surgery | a9523e11-70dc-40cb-9b0d-1dd63928d745 | 3233 | Cataract Surgery | 11.01.07 | {"3234": {"Id":3234,"MPAttachmentLetter":"A","Title":"ICD 10 codes for policy 11.01.07d, Cataract Surgery","MPPolicyAttachmentInternalSourceId":5477,"PolicyAttachmentPageName":"0c14c509-e3b3-4c66-8fee-360d2972c969"},} |
| | | 11.02.06m | CatheterAblationofCardiacArrhythmias11.02.06m | Surgery (11) | Catheter Ablation of Cardiac Arrhythmias | 5bc8fc6f-5bd5-4370-ab9e-ce20a42e10fe | 2659 | Catheter Ablation of Cardiac Arrhythmias | 11.02.06 | |
| | | 08.01.66 | Cemiplimab-rwlc (LIBTAYO®) | Pharmacy (08) | Cemiplimab-rwlc (LIBTAYO®) | 85256AA800623D7A8525857A004FE849 | 2398 | Cemiplimab-rwlc (LIBTAYO®) | 08.01.66 | |
| | | 08.01.39c | Cerliponasealfa(Brineura®)08.01.39c | Pharmacy (08) | Cerliponase alfa (Brineura®) | d0bf9cac-5008-4f9d-a225-598e388f07d8 | 3188 | Cerliponase alfa (Brineura®) | 08.01.39 | |
| | | 05.00.61g | CervicalTractionDevicesforIn-homeUse05.00.61g | DME (05) | Cervical Traction Devices for In-home Use | a11f7cc3-9d42-42f0-8f28-deb4b0380548 | 2640 | Cervical Traction Devices for In-home Use | 05.00.61 | |
| | | 08.00.67l | Cetuximab (Erbitux®) | Pharmacy (08) | Cetuximab (Erbitux®) | 85256AA800623D7A8525846C00638C9B | 1920 | Cetuximab (Erbitux®) | 08.00.67 | {"2273": {"Id":2273,"MPAttachmentLetter":"A","Title":"Dosing and Frequency Requirements","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A8525846C00638CAA"},"2274": {"Id":2274,"MPAttachmentLetter":"B","Title":"ICD-10 Codes for Cetuximab (Erbitux®)","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A8525846C00638CA4"},} |
| | | 11.08.08g | ChemicalPeels11.08.08g | Surgery (11) | Chemical Peels | 7bbf486e-20bb-4661-a6b8-817953106101 | 2662 | Chemical Peels | 11.08.08 | |
| | | 08.01.43h | ChimericAntigenReceptor(CAR)Therapy08.01.43h | Pharmacy (08) | Chimeric Antigen Receptor (CAR) Therapy | 63ad27c6-7e23-444b-bfa4-8c05c03a06b8 | 3363 | Chimeric Antigen Receptor (CAR) Therapy | 08.01.43 | {"3364": {"Id":3364,"MPAttachmentLetter":"A","Title":"ICD-10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":5617,"PolicyAttachmentPageName":"b42386b5-d935-4c1e-a24b-2dfec144f1d1"},} |
| | | 10.02.02j | ChiropracticSpinalandExtraspinalManipulationTherapy10.02.02j | Rehabilitation Services (10) | Chiropractic Spinal and Extraspinal Manipulation Therapy | c042c02a-0451-49be-a2c5-a513ea157169 | 3280 | Chiropractic Spinal and Extraspinal Manipulation Therapy | 10.02.02 | |
| | | 08.00.92ac | CoagulationFactors08.00.92ac | Pharmacy (08) | Coagulation Factors | 465ad1f4-30bc-45ac-8114-468e0f652a26 | 2736 | Coagulation Factors | 08.00.92 | |
| | | 06.02.54a | Cobalamin(VitaminB12),FolicAcid,andHomocysteineTesting06.02.54a | Pathology and Laboratory (06) | Cobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing | 7cb2da95-c713-46c9-ad44-10da7132a337 | 2795 | Cobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing | 06.02.54 | {"2796": {"Id":2796,"MPAttachmentLetter":"A","Title":"MEDICALLY NECESSARY ICD 10 CODES FOR COBALAMIN (VITAMIN B12) AND/OR FOLIC ACID TESTING (CPT CODES 82607, 82608, 82746, AND 82747)","MPPolicyAttachmentInternalSourceId":4910,"PolicyAttachmentPageName":"3f38e38f-1a5e-4b0a-933d-2b46ca742a4d"},} |
| | | 11.01.02p | CochlearImplant11.01.02p | Surgery (11) | Cochlear Implant | 52e574a3-d754-4e64-ae47-a5d0662891ef | 3123 | Cochlear Implant | 11.01.02 | |
| | | 08.01.71 | Collagenaseclostridiumhistolyticum(Xiaflex®),collagenaseclostridiumhistolyticum-aaes(Qwo™)08.01.71 | Pharmacy (08) | Collagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo™) | 519fdc48-27be-4644-8075-53b91ac2863d | 2689 | Collagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo™) | 08.01.71 | |
| | | 11.03.12t | ColorectalCancerScreening11.03.12t | Surgery (11) | Colorectal Cancer Screening | f7fbacdf-3a64-436d-99a7-7750aa0ab7d1 | 3357 | Colorectal Cancer Screening | 11.03.12 | |
| | | 12.00.03g | Complementary and Integrative Health Services | Miscellaneous (12) | Complementary and Integrative Health Services | B55889244594F1F085258574005DA579 | 2104 | Complementary and Integrative Health Services | 12.00.03 | |
| | | 07.06.01b | CompleteDecongestiveTherapy(CDT)07.06.01b | Medicine (07) | Complete Decongestive Therapy (CDT) | 74d20bbd-cd53-4d56-b994-33ea919b217c | 3330 | Complete Decongestive Therapy (CDT) | 07.06.01 | |
| | | 11.14.30 | CompositeTissueAllotransplantationoftheHand(s)andFace11.14.30 | Surgery (11) | Composite Tissue Allotransplantation of the Hand(s) and Face | cfc67080-f181-438d-9190-d1df58f6bc1d | 3197 | Composite Tissue Allotransplantation of the Hand(s) and Face | 11.14.30 | |
| | | 05.00.37f | CompressionGarments05.00.37f | DME (05) | Compression Garments | edddd201-1bf2-479f-9f86-1fd2713538d5 | 3195 | Compression Garments | 05.00.37 | |
| | | 09.00.42c | Computer-Aided Detection (CAD) System for Use with Chest Radiographs | Radiology (09) | Computer-Aided Detection (CAD) System for Use with Chest Radiographs | 85256AA800623D7A852584F2004C9E48 | 1988 | Computer-Aided Detection (CAD) System for Use with Chest Radiographs | 09.00.42 | |
| | | 11.14.17e | Computer-assistedMusculoskeletalSurgicalNavigationalOrthopedicProcedure11.14.17e | Surgery (11) | Computer-assisted Musculoskeletal Surgical Navigational Orthopedic Procedure | 997a85b5-16c6-4037-9e9a-30ef7a8f47c8 | 3199 | Computer-assisted Musculoskeletal Surgical Navigational Orthopedic Procedure | 11.14.17 | |
| | | 00.01.69 | Consultation Services | Administrative (00) | Consultation Services | F3BA7DB0E980312B8525854B005EE64C | 2172 | Consultation Services | 00.01.69 | |
| | | 07.13.11j | ContactLensesfortheTreatmentofPersistent(Corneal)EpithelialDefects07.13.11j | Medicine (07) | Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects | 7e953cdf-6f32-49a8-b2df-1f780a7d242d | 2649 | Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects | 07.13.11 | {"2650": {"Id":2650,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":4947,"PolicyAttachmentPageName":"ac05b158-f2de-4614-81cc-945829898efa"},} |
| | | 09.00.11e | ContrastAgentsUsedinConjunctionwithEchocardiography09.00.11e | Radiology (09) | Contrast Agents Used in Conjunction with Echocardiography | 486b7833-e733-47e1-a5a2-1fb22d353084 | 3091 | Contrast Agents Used in Conjunction with Echocardiography | 09.00.11 | |
| | | 07.13.07k | CornealPachymetryUsingUltrasound07.13.07k | Medicine (07) | Corneal Pachymetry Using Ultrasound | 985d887d-5350-4c1c-ba1d-4dd28827fdc5 | 2651 | Corneal Pachymetry Using Ultrasound | 07.13.07 | {"2652": {"Id":2652,"MPAttachmentLetter":"A","Title":"ICD-10-CM codes","MPPolicyAttachmentInternalSourceId":4969,"PolicyAttachmentPageName":"eb3a5e1b-6833-42ae-88c0-4bc890ca50cb"},} |
| | | 12.01.03a | CosmeticProcedures12.01.03a | Miscellaneous (12) | Cosmetic Procedures | 70aeb740-4e46-455e-abef-c6d9421a64e8 | 3329 | Cosmetic Procedures | 12.01.03 | |
| | | 05.00.04e | Coverage of Medical Devices | DME (05) | Coverage of Medical Devices | 85256AA800623D7A852583F900647246 | 2140 | Coverage of Medical Devices | 05.00.04 | |
| | | 08.01.08e | CoverageofAnticancerPrescriptionOralandInjectableDrugsandBiologicsandSupportiveAgents08.01.08e | Pharmacy (08) | Coverage of Anticancer Prescription Oral and Injectable Drugs and Biologics and Supportive Agents | 8e1f5bce-8640-4c5d-a1cf-6b2c1c5a7d98 | 3335 | Coverage of Anticancer Prescription Oral and Injectable Drugs and Biologics and Supportive Agents | 08.01.08 | {} |
| | | 05.00.80A | CranialElectrotherapyStimulation05.00.80A | DME (05) | Cranial Electrotherapy Stimulation | 57d5d404-40e8-4bca-b4b5-39fe907e8b06 | 2612 | Cranial Electrotherapy Stimulation | 05.00.80 | |
| | | 05.00.25i | CranialRemoldingOrthoses(Helmets)05.00.25i | DME (05) | Cranial Remolding Orthoses (Helmets) | 81e6e200-2094-43e9-804d-25c02aa5f8bf | 2998 | Cranial Remolding Orthoses (Helmets) | 05.00.25 | |
| | | 00.10.03j | Criteria for Reimbursement of Emergency Room Services | Administrative (00) | Criteria for Reimbursement of Emergency Room Services | 85256AA800623D7A852584710058EC0E | 2001 | Criteria for Reimbursement of Emergency Room Services | 00.10.03 | |
| | | 08.00.04 | crizanlizumab-tmca(Adakveo®)08.00.04 | Pharmacy (08) | crizanlizumab-tmca (Adakveo®) | f6a258a4-1a08-4ad9-aee7-39f1f23d4fb6 | 3175 | crizanlizumab-tmca (Adakveo®) | 08.00.04 | |
| | | 11.11.03d | CryosurgicalAblationoftheProstateGland11.11.03d | Surgery (11) | Cryosurgical Ablation of the Prostate Gland | 6398d8a3-6df3-482a-8408-a2ac2e2ee22b | 3203 | Cryosurgical Ablation of the Prostate Gland | 11.11.03 | |
| | | 08.01.29i | Daratumumab(Darzalex®),Daratumumab,andHyaluronidase-fihj(DarzalexFaspro®)08.01.29i | Pharmacy (08) | Daratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro®) | c52b181a-c56d-458d-b762-7932fdcf8937 | 3289 | Daratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro®) | 08.01.29 | |
| | | 10.00.02c | DayRehabilitation10.00.02c | Rehabilitation Services (10) | Day Rehabilitation | 7af90fad-1979-498e-98f3-5da73f3bfad9 | 3351 | Day Rehabilitation | 10.00.02 | |
| | | 11.08.17j | DebridementofMycoticandSymptomaticNon-MycoticHypertrophicToeNails11.08.17j | Surgery (11) | Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails | 33aa1c31-7602-42c4-8075-ccec6fc29a36 | 3027 | Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails | 11.08.17 | {"3028": {"Id":3028,"MPAttachmentLetter":"E","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (S86.892A - Z79.01), Continued","MPPolicyAttachmentInternalSourceId":5296,"PolicyAttachmentPageName":"b50a61b2-3cfb-4f88-81f8-e741a133067c"},"3029": {"Id":3029,"MPAttachmentLetter":"D","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (I87.099 - S86.891S), Continued","MPPolicyAttachmentInternalSourceId":5297,"PolicyAttachmentPageName":"7a6ed3b0-a09a-4cb3-80b7-42e4a2536e53"},"3030": {"Id":3030,"MPAttachmentLetter":"B","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (E10.22 - E13.3512), Continued","MPPolicyAttachmentInternalSourceId":5298,"PolicyAttachmentPageName":"63d1e27a-af1c-4bf4-9eb5-b955e1df424a"},"3031": {"Id":3031,"MPAttachmentLetter":"C","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (E13.3513 - I87.093), Continued","MPPolicyAttachmentInternalSourceId":5299,"PolicyAttachmentPageName":"85cde37e-28a7-41f2-92cb-d7566763a4a7"},"3032": {"Id":3032,"MPAttachmentLetter":"A","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (A30.0 -E10.21)","MPPolicyAttachmentInternalSourceId":5300,"PolicyAttachmentPageName":"02e7eab5-d819-4149-ab43-c2312ee1fe20"},} |
| | | 11.15.20p | DeepBrainStimulation(DBS)11.15.20p | Surgery (11) | Deep Brain Stimulation (DBS) | 3ecc3555-70b4-4662-ae43-bfa5024ef24e | 2629 | Deep Brain Stimulation (DBS) | 11.15.20 | |
| | | 11.15.09o | DenervationoftheSpinalNervesforChronicPain(IndependenceAdministrators)11.15.09o | Surgery (11) | Denervation of the Spinal Nerves for Chronic Pain (Independence Administrators) | b05afb73-aba6-464c-9acf-1d4e934cc883 | 2928 | Denervation of the Spinal Nerves for Chronic Pain (Independence Administrators) | 11.15.09 | |
| | | 08.00.94o | Denosumab(Prolia®,Xgeva®),Romosozumab-aqqg(Evenity®)08.00.94o | Pharmacy (08) | Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity®) | 0f6392a1-2719-450d-980d-71109cfbbf99 | 3185 | Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity®) | 08.00.94 | {"3186": {"Id":3186,"MPAttachmentLetter":"A","Title":"ICD-10-CM Codes","MPPolicyAttachmentInternalSourceId":5349,"PolicyAttachmentPageName":"1cf1d69b-23e3-49fb-82c0-805cfc574fa9"},} |
| | | 00.03.02ab | DiagnosticRadiologyServicesIncludedinCapitation00.03.02ab | Administrative (00) | Diagnostic Radiology Services Included in Capitation | ef37cab5-6501-4d87-acad-5bf9060d23d4 | 2960 | Diagnostic Radiology Services Included in Capitation | 00.03.02 | {"2961": {"Id":2961,"MPAttachmentLetter":"A","Title":"Diagnostic Radiology Procedure Codes Included in Capitation for Pennsylvania (PA) Health Maintenance Organization (HMO) Members","MPPolicyAttachmentInternalSourceId":5246,"PolicyAttachmentPageName":"1a071f00-e2c4-47cb-9af9-e77692b0d24c"},} |
| | | 00.09.01h | DirectAccesstoObstetrics/Gynecology(OB/GYN)Services00.09.01h | Administrative (00) | Direct Access to Obstetrics/Gynecology (OB/GYN) Services | 9c981601-10cc-4167-a854-9da704832694 | 2912 | Direct Access to Obstetrics/Gynecology (OB/GYN) Services | 00.09.01 | {"2913": {"Id":2913,"MPAttachmentLetter":"A","Title":"Procedure Codes for Direct Access OB/GYN","MPPolicyAttachmentInternalSourceId":5193,"PolicyAttachmentPageName":"06aff05f-ffda-49be-930f-087f93089d77"},} |
| | | 08.00.49e | Dofetilide(Tikosyn®)UseintheInpatientSetting08.00.49e | Pharmacy (08) | Dofetilide (Tikosyn®) Use in the Inpatient Setting | dbbe3feb-80d9-4d66-bbd2-6135accf52d1 | 3210 | Dofetilide (Tikosyn®) Use in the Inpatient Setting | 08.00.49 | |
| | | 08.01.79 | Dostarlimab-gxly(Jemperli)08.01.79 | Pharmacy (08) | Dostarlimab-gxly (Jemperli) | f8b18be7-798d-4e08-8bad-cf21497a7d5f | 3432 | Dostarlimab-gxly (Jemperli) | 08.01.79 | |
| | | 07.05.07d | Drug-ElutingBeadsandBlandEmbolizationfortheTreatmentofHepaticMalignancies07.05.07d | Medicine (07) | Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies | e6e62a11-5776-4052-ab2f-c0631761df82 | 2637 | Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies | 07.05.07 | |
| | | 08.01.37a | Drugs Used for the Maintenance Treatment of Opioid or Alcohol Use Disorder (e.g., Naltrexone Implants, Probuphine Implant, Sublocade Injection, Vivitrol Injection) | Pharmacy (08) | Drugs Used for the Maintenance Treatment of Opioid or Alcohol Use Disorder (e.g., Naltrexone Implants, Probuphine Implant, Sublocade Injection, Vivitrol Injection) | 85256AA800623D7A8525820B004EC0DE | 1894 | Drugs Used for the Maintenance Treatment of Opioid or Alcohol Use Disorder (e.g., Naltrexone Implants, Probuphine Implant, Sublocade Injection, Vivitrol Injection) | 08.01.37 | |
| | | 05.00.21x | DurableMedicalEquipment(DME)andConsumableMedicalSupplies05.00.21x | DME (05) | Durable Medical Equipment (DME) and Consumable Medical Supplies | 2a6d2214-b38f-490e-9a46-c9e6f6c40534 | 3109 | Durable Medical Equipment (DME) and Consumable Medical Supplies | 05.00.21 | {"3110": {"Id":3110,"MPAttachmentLetter":"A2","Title":"Equipment that Meets the Definition of Durable Medical Equipment (DME)","MPPolicyAttachmentInternalSourceId":5441,"PolicyAttachmentPageName":"547937bd-4c8c-4550-9c31-c557b050a833"},"3111": {"Id":3111,"MPAttachmentLetter":"B","Title":"Items that Do Not Meet the Definition of Durable Medical Equipment (DME)","MPPolicyAttachmentInternalSourceId":5442,"PolicyAttachmentPageName":"26e7820a-d3fd-4300-839a-4635dbc12c26"},"3112": {"Id":3112,"MPAttachmentLetter":"A1","Title":"Equipment that Meets the Definition of Durable Medical Equipment (DME)","MPPolicyAttachmentInternalSourceId":5443,"PolicyAttachmentPageName":"7ac75f7d-b5a2-4cf6-bc44-374725641281"},} |
| | | 05.00.48k | DurableMedicalEquipment(DME)NotSubjecttoaRentaltoPurchaseMaximum05.00.48k | DME (05) | Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum | 7cae1a28-f168-4966-b786-0320a4fa96d4 | 2986 | Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum | 05.00.48 | |
