|  | | 08.00.62n | Abatacept(Orencia®)forInjectionforIntravenousUse08.00.62n | Pharmacy (08) | Abatacept (Orencia®) for Injection for Intravenous Use | 97732f74-96a1-4bb1-afbb-1545f50fc384 | 4255 | Abatacept (Orencia®) for Injection for Intravenous Use | 08.00.62 | {"4256": {"Id":4256,"MPAttachmentLetter":"A","Title":"ICD-10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":6281,"PolicyAttachmentPageName":"c2a486e7-2984-4e36-ac6e-51e8cf5f261c"},} |
| | | 12.00.01g | Acupuncture12.00.01g | Miscellaneous (12) | Acupuncture | 90f4d9f6-e63e-44ce-bb4c-07427876022f | 5307 | Acupuncture | 12.00.01 | {"5308": {"Id":5308,"MPAttachmentLetter":"A","Title":"ICD-10 CM Codes Eligible to be Reported for Acupuncture","MPPolicyAttachmentInternalSourceId":7392,"PolicyAttachmentPageName":"64e78796-6b9b-4492-a019-2db2f21403d5"},} |
| | | 12.04.04b | AcuteCareFacilityInpatientTransfers12.04.04b | Miscellaneous (12) | Acute Care Facility Inpatient Transfers | 196a372b-a2c6-4a5e-9500-c722bf5a13da | 4701 | Acute Care Facility Inpatient Transfers | 12.04.04 | |
| | | 08.01.11h | Ado-TrastuzumabEmtansine(Kadcyla®)08.01.11h | Pharmacy (08) | Ado-Trastuzumab Emtansine (Kadcyla®) | 839b21f4-dacb-4c09-ab51-ee66bbe07f5f | 4879 | Ado-Trastuzumab Emtansine (Kadcyla®) | 08.01.11 | {"4880": {"Id":4880,"MPAttachmentLetter":"A","Title":"ICD-10-CM Codes and Narratives","MPPolicyAttachmentInternalSourceId":6792,"PolicyAttachmentPageName":"5ec33a2f-b084-411c-a40a-e217523ca6a2"},} |
| | | 08.01.93 | Aducanumab(Aduhelm)forAlzheimerDisease08.01.93 | Pharmacy (08) | Aducanumab (Aduhelm) for Alzheimer Disease | 69ef36af-da99-4769-9736-f75c7098f22f | 4365 | Aducanumab (Aduhelm) for Alzheimer Disease | 08.01.93 | |
| | | 08.00.69c | Agalsidasebeta(Fabrazyme®)08.00.69c | Pharmacy (08) | Agalsidase beta (Fabrazyme®) | 62f7ab0b-f175-47c9-a8c3-1b9de01b6521 | 5088 | Agalsidase beta (Fabrazyme®) | 08.00.69 | |
| | | 12.04.03c | AirAmbulanceServices12.04.03c | Miscellaneous (12) | Air Ambulance Services | f52d73b7-5d77-4eb0-9121-f79f7ba84412 | 4971 | Air Ambulance Services | 12.04.03 | |
| | | 08.01.22d | Alemtuzumab(Lemtrada®)08.01.22d | Pharmacy (08) | Alemtuzumab (Lemtrada®) | 5cc13039-207a-45c4-91f6-c7c4d3e6778a | 5227 | Alemtuzumab (Lemtrada®) | 08.01.22 | |
| | | 08.00.72k | Alglucosidasealfa(e.g.,Lumizyme®),Avalglucosidasealfa-ngpt(Nexviazyme®)08.00.72k | Pharmacy (08) | Alglucosidase alfa (e.g., Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme® ) | 55b349d1-264d-43aa-9a17-4ece583a6923 | 5281 | Alglucosidase alfa (e.g., Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme® ) | 08.00.72 | |
| | | 07.00.21j | AllergyImmunotherapy07.00.21j | Medicine (07) | Allergy Immunotherapy | aa555f38-c3ef-429e-990c-f633f79e8ada | 4754 | Allergy Immunotherapy | 07.00.21 | |
| | | 08.01.88 | AllogeneicProcessedThymusTissue-agdc(Rethymic®)08.01.88 | Pharmacy (08) | Allogeneic Processed Thymus Tissue-agdc (Rethymic®) | cd295dbf-3ea0-44ef-93bf-207a1a2b64e8 | 5103 | Allogeneic Processed Thymus Tissue-agdc (Rethymic®) | 08.01.88 | |
| | | 06.02.29d | AlloMap™MolecularExpressionTestingforHeartTransplantRejection(IndependenceAdministrators)06.02.29d | Pathology and Laboratory (06) | AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (Independence Administrators) | 418d9a77-331d-4b0e-81fd-b74f8fdcec75 | 5148 | 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®) | 1b5f038c-0f20-4a75-98b9-9166968f5086 | 5154 | Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP®, Glassia®, Zemaira®) | 08.00.91 | |
| | | 00.01.52r | AlwaysBundledProcedureCodes00.01.52r | Administrative (00) | Always Bundled Procedure Codes | edc1e758-8fc8-48ff-a282-ffeae40028ee | 4977 | Always Bundled Procedure Codes | 00.01.52 | {"4978": {"Id":4978,"MPAttachmentLetter":"B","Title":"Procedures/Services Not Eligible for Separate Reimbursement","MPPolicyAttachmentInternalSourceId":7148,"PolicyAttachmentPageName":"81f27da3-41aa-4847-a440-a65b4c9560ce"},"4979": {"Id":4979,"MPAttachmentLetter":"A","Title":"Always Bundled Procedures (Indicator B)","MPPolicyAttachmentInternalSourceId":7149,"PolicyAttachmentPageName":"0464e5ef-36e4-4667-9672-9e4eb83a84d9"},"4980": {"Id":4980,"MPAttachmentLetter":"C","Title":"Procedures/Services Not Eligible for Reimbursement","MPPolicyAttachmentInternalSourceId":7150,"PolicyAttachmentPageName":"c6170f71-54cf-4562-8821-5ed046f758e0"},} |
| | | 07.02.09h | AmbulatoryBloodPressureMonitoring(ABPM)andHomeBloodPressureMonitoring(HBPM)Devices07.02.09h | Medicine (07) | Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices | 4a322af8-4167-4e02-afbd-8599b1656895 | 4807 | Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices | 07.02.09 | |
| | | 07.02.21k | AmbulatoryElectrocardiography(AECG)MonitoringandMobileCardiacOutpatientTelemetry(MCOT)Monitoring07.02.21k | Medicine (07) | Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring | 05e1f864-5736-4586-addf-3987bbec25fc | 4910 | Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring | 07.02.21 | |
| | | 01.00.12a | AnesthesiaServicesforEpidural,ParavertebralFacetandSacroiliacJointInjectionsforSpinalJointManagement01.00.12a | Anesthesia (01) | Anesthesia Services for Epidural, Paravertebral Facet and Sacroiliac Joint Injections for Spinal Joint Management | ead4c7e8-3eb9-4efb-9c14-02e79aa4b05d | 5304 | Anesthesia Services for Epidural, Paravertebral Facet and Sacroiliac Joint Injections for Spinal Joint Management | 01.00.12 | {"5305": {"Id":5305,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":7396,"PolicyAttachmentPageName":"f37f4f7f-f536-41be-ae99-724fd292eacf"},} |
| | | 08.01.82b | Anifrolumab-fnia(Saphnelo™)08.01.82b | Pharmacy (08) | Anifrolumab-fnia (Saphnelo™) | 2fdd9022-2641-49f8-ae4f-b09593402c69 | 4246 | Anifrolumab-fnia (Saphnelo™) | 08.01.82 | |
| | | 05.00.39s | Ankle-Foot/Knee-Ankle-FootOrthoses05.00.39s | DME (05) | Ankle-Foot/Knee-Ankle-Foot Orthoses | 35274498-d997-4f99-94a3-0d42f685e2be | 5084 | Ankle-Foot/Knee-Ankle-Foot Orthoses | 05.00.39 | {"5085": {"Id":5085,"MPAttachmentLetter":"A","Title":"HCPCS Codes","MPPolicyAttachmentInternalSourceId":7044,"PolicyAttachmentPageName":"b121dd27-32ef-4c9d-a81a-a61ed2b9126f"},} |
| | | 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 | 76f815fa-14c4-4531-8c3f-bc8fe0de4f6f | 5032 | Application and Removal of Tattoos | 11.08.05 | |
| | | 14.00.03 | AppliedBehaviorAnalysis(ABA)fortheTreatmentofAutismSpectrumDisorders(ASD)14.00.03 | Behavioral Health (14) | Applied Behavior Analysis (ABA) for the Treatment of Autism Spectrum Disorders (ASD) | 8e21f681-8261-4b8d-924b-59e9f4a8b449 | 4967 | Applied Behavior Analysis (ABA) for the Treatment of Autism Spectrum Disorders (ASD) | 14.00.03 | |
| | | 08.01.41e | Aprepitant(Cinvanti™),FosaprepitantDimeglumine(Emend®),Granisetron(Sustol®),andRolapitant(Varubi®)08.01.41e | Pharmacy (08) | Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®) | 68b0db08-bc36-4791-bc21-24234f4c1097 | 4923 | Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®) | 08.01.41 | {"4924": {"Id":4924,"MPAttachmentLetter":"A","Title":"Risk of Emesis Without Prophylaxis: Intravenous and Oral Antineoplastic Agents","MPPolicyAttachmentInternalSourceId":7122,"PolicyAttachmentPageName":"fe7db1ca-7fea-41ca-8b4d-26bae30635bf"},} |
| | | 11.05.16l | AqueousShunts,Microstents,Viscocanalostomy,andCanaloplastyfortheTreatmentofGlaucoma11.05.16l | Surgery (11) | Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma | 247cb6c3-4717-4406-9763-45a7e18e9743 | 4928 | Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma | 11.05.16 | {"4929": {"Id":4929,"MPAttachmentLetter":"A","Title":"ICD-10 codes","MPPolicyAttachmentInternalSourceId":7061,"PolicyAttachmentPageName":"a0d68167-5052-4bab-8ea3-c25cff7e560b"},} |
| | | 11.14.19p | ArtificialIntervertebralCervicalDiscInsertion(IndependenceAdministrators)11.14.19p | Surgery (11) | Artificial Intervertebral Cervical Disc Insertion (Independence Administrators) | ec54656d-1d31-41b0-b458-e1a4358b0ed7 | 5233 | Artificial Intervertebral Cervical Disc Insertion (Independence Administrators) | 11.14.19 | |
| | | 11.15.31b | ArtificialIntervertebralLumbarDiscInsertion11.15.31b | Surgery (11) | Artificial Intervertebral Lumbar Disc Insertion | 1a1546d8-2f70-47e9-80e8-be03e5acd487 | 4919 | Artificial Intervertebral Lumbar Disc Insertion | 11.15.31 | |
| | | 08.01.35f | AsparaginaseErwiniaChrysanthemi(Erwinaze®),asparaginaseerwiniachrysanthemi(recombinant)-rywn(Rylaze™)08.01.35f | Pharmacy (08) | Asparaginase Erwinia Chrysanthemi (Erwinaze®), asparaginase erwinia chrysanthemi (recombinant)-rywn (Rylaze™) | 6160580f-3e49-4886-a470-2c0b3f1203a0 | 4488 | Asparaginase Erwinia Chrysanthemi (Erwinaze®), asparaginase erwinia chrysanthemi (recombinant)-rywn (Rylaze™) | 08.01.35 | |
| | | 06.02.27n | AssaysofGeneticExpressioninTumorTissueforBreastCancerPrognosis(IndependenceAdministrators)06.02.27n | Pathology and Laboratory (06) | Assays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis (Independence Administrators) | faea9ca0-5aaf-4df6-b345-ecb509a725f6 | 4445 | 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 | 76727854-57be-4f5a-a359-c836ddd2fe12 | 4795 | Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation | 07.10.06 | |
| | | 08.01.69c | Atezolizumab(Tecentriq®)08.01.69c | Pharmacy (08) | Atezolizumab (Tecentriq®) | ab4a9746-3c0a-4512-bd38-0b178d74977d | 5045 | Atezolizumab (Tecentriq®) | 08.01.69 | {"5046": {"Id":5046,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":7179,"PolicyAttachmentPageName":"0d497a54-8cfd-430b-9dff-dd040a596b3c"},} |
| | | 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) | 561dc9ad-1c1e-407e-9e75-bd02a965bf10 | 5162 | Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions (Independence Administrators) | 11.14.06 | |
| | | 05.00.29n | AutomaticExternalCardioverterDefibrillators(WearableandNonwearable)05.00.29n | DME (05) | Automatic External Cardioverter Defibrillators (Wearable and Nonwearable) | 148bea2e-d96c-412f-a00c-62599efec1ea | 4804 | Automatic External Cardioverter Defibrillators (Wearable and Nonwearable) | 05.00.29 | {"4805": {"Id":4805,"MPAttachmentLetter":"B","Title":"ICD-10 codes used to represent the Nonwearable Automatic External Defibrillator (AED):","MPPolicyAttachmentInternalSourceId":6577,"PolicyAttachmentPageName":"1029c90a-ad3b-4599-ba3e-31bee5b3f07e"},"4806": {"Id":4806,"MPAttachmentLetter":"A","Title":"ICD-10 Codes used to represent the Wearable Automatic External Defibrillator (AED):","MPPolicyAttachmentInternalSourceId":6578,"PolicyAttachmentPageName":"db6d5721-d139-4eed-bd31-29417ff0f7a8"},} |
| | | 07.03.23f | AutonomicNervousSystemTesting07.03.23f | Medicine (07) | Autonomic Nervous System Testing | 6acca538-d91c-41c4-a64c-7e8d2930e58c | 5262 | Autonomic Nervous System Testing | 07.03.23 | |
| | | 08.01.64b | Avelumab(Bavencio®)08.01.64b | Pharmacy (08) | Avelumab (Bavencio®) | 89f5a884-1725-46ed-91bb-b7944b71287c | 4888 | Avelumab (Bavencio®) | 08.01.64 | {"4889": {"Id":4889,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":7008,"PolicyAttachmentPageName":"dd583577-e9f1-40f6-8c23-ea98e3eaedbc"},} |
| | | 11.16.06j | BalloonCatheterDilationofSinusOstiaforTreatmentofChronicRhinosinusitis11.16.06j | Surgery (11) | Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis | 24f38e25-4fbe-4329-b23f-2b507113624c | 5021 | 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) | 2a68daca-621e-4826-8bcf-e5212ad5e2c1 | 4215 | Belantamab mafodotin-blmf (Blenrep) | 08.01.70 | |
| | | 08.00.99e | Belimumab(Benlysta®)forIntravenousUse08.00.99e | Pharmacy (08) | Belimumab (Benlysta®) for Intravenous Use | b9da618c-f1df-4a91-bdec-7d467008d14f | 5225 | Belimumab (Benlysta®) for Intravenous Use | 08.00.99 | |
| | | 08.01.89 | BetibeglogeneAutotemcel[Beti-Cel(ZYNTEGLO®)]08.01.89 | Pharmacy (08) | Betibeglogene Autotemcel [Beti-Cel (ZYNTEGLO®)] | a621d3f8-8991-44aa-9f0c-83bd74ddb3aa | 4900 | Betibeglogene Autotemcel [Beti-Cel (ZYNTEGLO®)] | 08.01.89 | |
| | | 08.00.66u | Bevacizumab(Avastin®)andRelatedBiosimilarsForOncologicUse08.00.66u | Pharmacy (08) | Bevacizumab (Avastin®) and Related Biosimilars For Oncologic Use | 4f5fba6f-e0af-4ca7-ae67-ee9a82fff8e6 | 5313 | Bevacizumab (Avastin®) and Related Biosimilars For Oncologic Use | 08.00.66 | {"5314": {"Id":5314,"MPAttachmentLetter":"A","Title":"Dosing and Frequency Requirements","MPPolicyAttachmentInternalSourceId":7256,"PolicyAttachmentPageName":"b25c28fb-b5eb-4152-9bca-95087ce19862"},"5315": {"Id":5315,"MPAttachmentLetter":"B","Title":"ICD 10 Diagnosis Codes","MPPolicyAttachmentInternalSourceId":7322,"PolicyAttachmentPageName":"bdf82e0b-98c1-4c3c-8545-71d281a15389"},} |
| | | 00.10.39p | BillingforProfessionalOffice-BasedServicesPerformedinanOutpatientOffice-BasedSettingLocatedwithinaFacilityoronaFacilityCampus00.10.39p | Administrative (00) | Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus | 947f2068-3357-4b3b-a661-61dc273ccbf7 | 5006 | 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 | {"5007": {"Id":5007,"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":7191,"PolicyAttachmentPageName":"7fa7063b-493d-48fa-8a2b-dca1075b3ba1"},} |
| | | 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 | 9e8bccdf-78f9-49b6-8222-e6c92e62d35a | 5048 | Biofeedback Therapy | 07.00.01 | |
| | | 07.06.03b | BioimpedencefortheDetectionofLymphedema07.06.03b | Medicine (07) | Bioimpedence for the Detection of Lymphedema | 003a2876-c32d-49ee-acdf-0694a0faee57 | 4307 | 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 | 0004caa3-4725-461b-a8f6-5dc4564e1a27 | 4779 | Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy | 11.05.02 | {"4780": {"Id":4780,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":6997,"PolicyAttachmentPageName":"192874a4-9925-4785-8097-96d4fd434cf0"},} |
| | | 08.01.21f | Blinatumomab(Blincyto®)08.01.21f | Pharmacy (08) | Blinatumomab (Blincyto®) | 210e5872-ee1f-4197-bbec-c07c8d759d25 | 5039 | Blinatumomab (Blincyto®) | 08.01.21 | |
| | | 11.01.06g | Bone-Anchored(Osseointegrated)HearingAidsandImplantableMiddleEarHearingAids11.01.06g | Surgery (11) | Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids | 646ded68-0b53-483b-ab2f-64b834419e12 | 4958 | Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids | 11.01.06 | |
| | | 09.00.04m | BoneMineralDensity(BMD)Testing09.00.04m | Radiology (09) | Bone Mineral Density (BMD) Testing | f2fb6729-651e-443f-91c7-d930178ab96b | 4911 | Bone Mineral Density (BMD) Testing | 09.00.04 | |
| | | 08.00.73o | Bortezomib(BortezomibforInjection,Velcade®)08.00.73o | Pharmacy (08) | Bortezomib (Bortezomib for Injection, Velcade®) | ecbaf100-2489-4636-8a27-4f9678265689 | 4948 | Bortezomib (Bortezomib for Injection, Velcade®) | 08.00.73 | {"4949": {"Id":4949,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":7118,"PolicyAttachmentPageName":"99426d3c-84b0-4a80-b5c1-174aaa0432af"},} |
| | | 08.00.26aa | BotulinumToxinAgents08.00.26aa | Pharmacy (08) | Botulinum Toxin Agents | 324992a7-5472-4f68-8491-b0500d42cfd4 | 5177 | Botulinum Toxin Agents | 08.00.26 | {"5178": {"Id":5178,"MPAttachmentLetter":"A","Title":"ICD-10 Diagnosis Codes","MPPolicyAttachmentInternalSourceId":7183,"PolicyAttachmentPageName":"d04f804c-5a87-4c86-b10a-303af437254c"},} |
| | | 09.00.10z | BrachytherapyandAcceleratedWholeBreastIrradiationusingThree-DimensionalConformationRadiationTherapy09.00.10z | Radiology (09) | Brachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation Therapy | 590723a8-759b-4b63-953f-9224ae10d439 | 4431 | Brachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation Therapy | 09.00.10 | |
| | | 05.00.76g | BreastPumps05.00.76g | DME (05) | Breast Pumps | 2c66e6e3-355b-468f-8023-0018ae375f9b | 4961 | Breast Pumps | 05.00.76 | |
| | | 08.01.13h | BrentuximabVedotin(Adcetris®)08.01.13h | Pharmacy (08) | Brentuximab Vedotin (Adcetris®) | 4ee019bd-e663-4061-9d7f-6547117431f4 | 4542 | Brentuximab Vedotin (Adcetris®) | 08.01.13 | {"4543": {"Id":4543,"MPAttachmentLetter":"A","Title":"ICD CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":6762,"PolicyAttachmentPageName":"722c0adb-e5cf-4d42-a2ac-eba09c2b0574"},} |
| | | 11.16.09 | BronchialValves11.16.09 | Surgery (11) | Bronchial Valves | c2b28475-247f-463e-9c3b-5a6ecc89c4d0 | 4080 | Bronchial Valves | 11.16.09 | |
| | | 08.01.49b | Burosumab-twza(Crysvita®)08.01.49b | Pharmacy (08) | Burosumab-twza (Crysvita®) | 25d7087c-ccb2-4eb7-8a83-dae2287e4fa3 | 5282 | Burosumab-twza (Crysvita®) | 08.01.49 | |
| | | 08.01.51b | Canakinumab(Ilaris®)08.01.51b | Pharmacy (08) | Canakinumab (Ilaris®) | 51cf7e36-9d4b-4e2b-a76c-03082412b979 | 5289 | Canakinumab (Ilaris®) | 08.01.51 | |
| | | 10.01.01o | CardiacRehabilitation(CR)andIntensiveCardiacRehabilitation(ICR)Programs10.01.01o | Rehabilitation Services (10) | Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs | 2adc54e6-00ed-4918-b193-578a35f6faef | 4554 | Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs | 10.01.01 | {"4555": {"Id":4555,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":6701,"PolicyAttachmentPageName":"08416812-7b9f-4ef0-8bc0-33e2425b725c"},} |
| | | 00.01.59m | CareManagementandCarePlanningServices00.01.59m | Administrative (00) | Care Management and Care Planning Services | 142a9bb0-7fee-4470-89dd-7f8c7299962c | 5008 | Care Management and Care Planning Services | 00.01.59 | |
| | | 08.01.05i | Carfilzomib(Kyprolis®)08.01.05i | Pharmacy (08) | Carfilzomib (Kyprolis®) | ea938bae-5423-4dc6-be25-b35f3444277f | 4747 | Carfilzomib (Kyprolis®) | 08.01.05 | |
| | | 00.10.15d | CastandSplintApplicationsandAssociatedSupplies00.10.15d | Administrative (00) | Cast and Splint Applications and Associated Supplies | 76b13cf3-92b8-4525-b937-062890962486 | 4299 | Cast and Splint Applications and Associated Supplies | 00.10.15 | {"4300": {"Id":4300,"MPAttachmentLetter":"A","Title":"Procedure Codes Related to Cast and Splint Applications and Associated Supplies","MPPolicyAttachmentInternalSourceId":6421,"PolicyAttachmentPageName":"ef40cfc7-9301-40ac-955b-042c21374443"},} |
| | | 11.01.07f | CataractSurgery11.01.07f | Surgery (11) | Cataract Surgery | f794b752-3310-4f3a-a3ae-80e0ae54c3fe | 4788 | Cataract Surgery | 11.01.07 | {"4789": {"Id":4789,"MPAttachmentLetter":"A","Title":"ICD 10 codes for policy 11.01.07d, Cataract Surgery","MPPolicyAttachmentInternalSourceId":6668,"PolicyAttachmentPageName":"a519d3f3-aa39-4f1b-a2e9-6abe8e559016"},} |
| | | 11.02.06o | CatheterAblationofCardiacArrhythmias11.02.06o | Surgery (11) | Catheter Ablation of Cardiac Arrhythmias | b7611a34-21f1-4818-ac64-8a8a5e47c3d4 | 4556 | Catheter Ablation of Cardiac Arrhythmias | 11.02.06 | |
| | | 08.01.66b | Cemiplimab-rwlc(Libtayo®)08.01.66b | Pharmacy (08) | Cemiplimab-rwlc (Libtayo®) | 5f720c24-c113-4d82-bcc7-4840c6911572 | 4886 | Cemiplimab-rwlc (Libtayo®) | 08.01.66 | |
| | | 08.01.39c | Cerliponasealfa(Brineura®)08.01.39c | Pharmacy (08) | Cerliponase alfa (Brineura®) | a8bbd22a-8279-42e6-bce7-e23c36601e5f | 5266 | Cerliponase alfa (Brineura®) | 08.01.39 | |
| | | 05.00.61g | CervicalTractionDevicesforIn-homeUse05.00.61g | DME (05) | Cervical Traction Devices for In-home Use | 7db4611a-daa5-4bb7-9dd6-fbec48738550 | 5108 | Cervical Traction Devices for In-home Use | 05.00.61 | |
| | | 08.00.67n | Cetuximab(Erbitux®)08.00.67n | Pharmacy (08) | Cetuximab (Erbitux®) | 1d2fc37e-88d7-431a-9aca-e9f20e57b894 | 4944 | Cetuximab (Erbitux®) | 08.00.67 | {"4945": {"Id":4945,"MPAttachmentLetter":"B","Title":"ICD-10 Codes for Cetuximab (Erbitux®)","MPPolicyAttachmentInternalSourceId":7025,"PolicyAttachmentPageName":"3076dda0-2a35-4c44-8472-ddea1e48e6a6"},"4946": {"Id":4946,"MPAttachmentLetter":"A","Title":"Dosing and Frequency Requirements","MPPolicyAttachmentInternalSourceId":7026,"PolicyAttachmentPageName":"f158ffaa-9a1b-498f-af64-a68cee2d7dfa"},} |
| | | 11.08.08h | ChemicalPeels11.08.08h | Surgery (11) | Chemical Peels | 7d28d8ee-4fcf-48ac-aaee-cfd8b31c3bfb | 4537 | Chemical Peels | 11.08.08 | |
| | | 08.01.43k | ChimericAntigenReceptor(CAR)Therapy08.01.43k | Pharmacy (08) | Chimeric Antigen Receptor (CAR) Therapy | 74afbcd9-65f3-4d96-bd95-8995043065c0 | 4540 | Chimeric Antigen Receptor (CAR) Therapy | 08.01.43 | {"4541": {"Id":4541,"MPAttachmentLetter":"A","Title":"ICD-10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":6560,"PolicyAttachmentPageName":"940358e1-043e-4889-b782-fe9a11c0ad48"},} |
| | | 10.02.02j | ChiropracticSpinalandExtraspinalManipulationTherapy10.02.02j | Rehabilitation Services (10) | Chiropractic Spinal and Extraspinal Manipulation Therapy | f970c42c-dd59-466f-8b6a-9f941ed5693c | 4753 | Chiropractic Spinal and Extraspinal Manipulation Therapy | 10.02.02 | |
| | | 08.00.92ae | CoagulationFactors08.00.92ae | Pharmacy (08) | Coagulation Factors | 22bc84c7-5553-4fa7-b5d3-be57e0cc24a3 | 4737 | Coagulation Factors | 08.00.92 | |
| | | 06.02.54c | Cobalamin(VitaminB12),FolicAcid,andHomocysteineTesting06.02.54c | Pathology and Laboratory (06) | Cobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing | c5499930-95f2-444b-a13e-1ac4defdf91b | 4993 | Cobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing | 06.02.54 | {"4994": {"Id":4994,"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":7156,"PolicyAttachmentPageName":"d03d4c64-525a-45ec-95d6-913e55453365"},} |
| | | 11.01.02q | CochlearImplantation11.01.02q | Surgery (11) | Cochlear Implantation | 92165f01-4385-42eb-a620-83ba4e4b607e | 4741 | Cochlear Implantation | 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™) | 0371d979-7a62-4d2e-89a7-3202eff71aa6 | 5069 | Collagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo™) | 08.01.71 | |
| | | 11.03.12t | ColorectalCancerScreening11.03.12t | Surgery (11) | Colorectal Cancer Screening | d791112d-6c87-4bc2-8a82-f564801d7237 | 4813 | Colorectal Cancer Screening | 11.03.12 | |
| | | 12.00.03g | ComplementaryandIntegrativeHealthServices12.00.03g | Miscellaneous (12) | Complementary and Integrative Health Services | 979c27fb-de3f-4cf5-82ba-0053b59f78b8 | 4301 | Complementary and Integrative Health Services | 12.00.03 | |
| | | 07.06.01b | CompleteDecongestiveTherapy(CDT)07.06.01b | Medicine (07) | Complete Decongestive Therapy (CDT) | 878f6379-6a66-4575-afb6-3c2568636bdd | 4306 | 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 | 2641be91-6b2d-457f-9cb2-2fd6c8fd3704 | 5018 | Composite Tissue Allotransplantation of the Hand(s) and Face | 11.14.30 | |
| | | 05.00.37g | CompressionGarments05.00.37g | DME (05) | Compression Garments | 0614114f-9368-4ca8-bdcf-164d35718d22 | 5172 | Compression Garments | 05.00.37 | |
| | | 09.00.42c | Computer-AidedDetection(CAD)SystemforUsewithChestRadiographs09.00.42c | Radiology (09) | Computer-Aided Detection (CAD) System for Use with Chest Radiographs | ddf4156a-01e2-4e9f-82fc-68aab25f027b | 5031 | 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 | 92e3212a-d739-4d86-a4ac-39c40334f32d | 5002 | Computer-assisted Musculoskeletal Surgical Navigational Orthopedic Procedure | 11.14.17 | |
| | | 00.01.69b | ConsultationServices00.01.69b | Administrative (00) | Consultation Services | eb4b646a-6ce3-45f1-9096-23e49da996df | 5009 | Consultation Services | 00.01.69 | |
| | | 07.13.11k | ContactLensesfortheTreatmentofPersistent(Corneal)EpithelialDefects07.13.11k | Medicine (07) | Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects | 96eca6bb-e268-40fb-89b6-dfeea7bb5fcc | 5065 | Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects | 07.13.11 | {"5066": {"Id":5066,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":7217,"PolicyAttachmentPageName":"af801910-b372-4ab7-aa5f-2a44ef5a7a72"},} |
| | | 09.00.11e | ContrastAgentsUsedinConjunctionwithEchocardiography09.00.11e | Radiology (09) | Contrast Agents Used in Conjunction with Echocardiography | 7c8e4bb0-6f66-4f72-84b4-101428132497 | 5063 | Contrast Agents Used in Conjunction with Echocardiography | 09.00.11 | |
| | | 07.13.07l | CornealPachymetryUsingUltrasound07.13.07l | Medicine (07) | Corneal Pachymetry Using Ultrasound | c53caf21-625e-421f-bca8-41cf258425ee | 4321 | Corneal Pachymetry Using Ultrasound | 07.13.07 | {"4322": {"Id":4322,"MPAttachmentLetter":"A","Title":"ICD-10-CM codes","MPPolicyAttachmentInternalSourceId":6351,"PolicyAttachmentPageName":"0ebc36ca-6a69-4baa-98bd-dac5e5555384"},} |
| | | 12.01.03a | CosmeticProcedures12.01.03a | Miscellaneous (12) | Cosmetic Procedures | 5196725f-47be-4c15-b422-5e38270922a7 | 4792 | Cosmetic Procedures | 12.01.03 | |
| | | 08.01.08l | CoverageofAnticancerPrescriptionOralandInjectableDrugsandBiologicsandSupportiveAgents08.01.08l | Pharmacy (08) | Coverage of Anticancer Prescription Oral and Injectable Drugs and Biologics and Supportive Agents | 6774b7e5-3dd0-409c-ae5e-a309a8744be8 | 5179 | Coverage of Anticancer Prescription Oral and Injectable Drugs and Biologics and Supportive Agents | 08.01.08 | {} |
| | | 05.00.04e | CoverageofMedicalDevices05.00.04e | DME (05) | Coverage of Medical Devices | 0e5a3246-799b-4df3-bc4a-9a5c0ec82166 | 3665 | Coverage of Medical Devices | 05.00.04 | |
| | | 05.00.80c | CranialElectrotherapyStimulation05.00.80c | DME (05) | Cranial Electrotherapy Stimulation | ab9638f7-dc59-4586-94c8-f2938d0b935e | 4698 | Cranial Electrotherapy Stimulation | 05.00.80 | |
| | | 05.00.25i | CranialRemoldingOrthoses(Helmets)05.00.25i | DME (05) | Cranial Remolding Orthoses (Helmets) | 44ec7026-b615-4208-b5f9-d8d4a51c949e | 5097 | Cranial Remolding Orthoses (Helmets) | 05.00.25 | |
| | | 00.10.03k | CriteriaforReimbursementofEmergencyRoomServices00.10.03k | Administrative (00) | Criteria for Reimbursement of Emergency Room Services | 1adfb9b5-6ec1-41a1-ab70-0ec7069d62d9 | 4962 | Criteria for Reimbursement of Emergency Room Services | 00.10.03 | |
| | | 08.00.04 | crizanlizumab-tmca(Adakveo®)08.00.04 | Pharmacy (08) | crizanlizumab-tmca (Adakveo®) | ead778d7-52e0-40ac-b20d-80866708fda4 | 5005 | crizanlizumab-tmca (Adakveo®) | 08.00.04 | |
| | | 11.11.03d | CryosurgicalAblationoftheProstateGland11.11.03d | Surgery (11) | Cryosurgical Ablation of the Prostate Gland | 5c410158-5c9f-4ee9-84e2-7e74e23e7cb1 | 4309 | Cryosurgical Ablation of the Prostate Gland | 11.11.03 | |
| | | 08.01.29j | Daratumumab(Darzalex®),Daratumumab,andHyaluronidase-fihj(DarzalexFaspro®)08.01.29j | Pharmacy (08) | Daratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro®) | d5ec64eb-6e3a-4e18-ae7a-2e1f3d824f86 | 4494 | Daratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro®) | 08.01.29 | |
| | | 10.00.02c | DayRehabilitation10.00.02c | Rehabilitation Services (10) | Day Rehabilitation | 1381b984-d385-4d3d-91a9-8daa23bf024f | 5297 | Day Rehabilitation | 10.00.02 | |
| | | 11.08.17k | DebridementofMycoticandSymptomaticNon-MycoticHypertrophicToeNails11.08.17k | Surgery (11) | Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails | 9aaa0244-d519-4cc2-b31f-9604c858383c | 5050 | Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails | 11.08.17 | {"5051": {"Id":5051,"MPAttachmentLetter":"E","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (S86.892A - Z79.01), Continued","MPPolicyAttachmentInternalSourceId":7200,"PolicyAttachmentPageName":"6c8c7cfa-378c-406d-a02e-62621d3d9036"},"5052": {"Id":5052,"MPAttachmentLetter":"B","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (E10.22 - E13.3512), Continued","MPPolicyAttachmentInternalSourceId":7201,"PolicyAttachmentPageName":"b8b7941f-bb7f-402f-8345-a5cfe9aa701e"},"5053": {"Id":5053,"MPAttachmentLetter":"D","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (I87.099 - S86.891S), Continued","MPPolicyAttachmentInternalSourceId":7202,"PolicyAttachmentPageName":"1b9df63e-76d7-492d-a66f-53868fc23379"},"5054": {"Id":5054,"MPAttachmentLetter":"A","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (A30.0 -E10.21)","MPPolicyAttachmentInternalSourceId":7203,"PolicyAttachmentPageName":"4a1f38b7-9d76-4aaa-920b-88cd4d7da417"},"5055": {"Id":5055,"MPAttachmentLetter":"C","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (E13.3513 - I87.093), Continued","MPPolicyAttachmentInternalSourceId":7204,"PolicyAttachmentPageName":"ea01801d-1b6b-4cba-9abb-1723eb41d976"},} |
| | | 11.15.20r | DeepBrainStimulation(DBS)11.15.20r | Surgery (11) | Deep Brain Stimulation (DBS) | e447a55a-6fa7-4a92-b4fe-ddc2d83e8dd8 | 5125 | Deep Brain Stimulation (DBS) | 11.15.20 | |
| | | 11.15.09p | DenervationoftheSpinalNervesforChronicPain(IndependenceAdministrators)11.15.09p | Surgery (11) | Denervation of the Spinal Nerves for Chronic Pain (Independence Administrators) | a62acc79-9c13-49a6-a11c-c6ff9a940219 | 5163 | Denervation of the Spinal Nerves for Chronic Pain (Independence Administrators) | 11.15.09 | |
| | | 08.00.94p | Denosumab(Prolia®,Xgeva®),Romosozumab-aqqg(Evenity®)08.00.94p | Pharmacy (08) | Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity®) | 798cca7f-66bc-4a18-89fe-800f61ffd321 | 4201 | Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity®) | 08.00.94 | {"4202": {"Id":4202,"MPAttachmentLetter":"A","Title":"ICD-10-CM Codes","MPPolicyAttachmentInternalSourceId":6188,"PolicyAttachmentPageName":"1bd93b63-74c0-4ee5-99ad-a91d50c40edf"},} |
| | | 11.16.01j | DermabrasionforRhinophyma,Septoplasty,Rhinoplasty,andSeptorhinoplasty11.16.01j | Surgery (11) | Dermabrasion for Rhinophyma, Septoplasty, Rhinoplasty, and Septorhinoplasty | a67fb1d0-89a2-439a-919a-39d46565e6a9 | 4930 | Dermabrasion for Rhinophyma, Septoplasty, Rhinoplasty, and Septorhinoplasty | 11.16.01 | |
| | | 00.03.02ad | DiagnosticRadiologyServicesIncludedinCapitation00.03.02ad | Administrative (00) | Diagnostic Radiology Services Included in Capitation | e3772d4e-89a5-4eaf-b900-f06b47d8f372 | 4935 | Diagnostic Radiology Services Included in Capitation | 00.03.02 | {"4936": {"Id":4936,"MPAttachmentLetter":"A","Title":"Diagnostic Radiology Procedure Codes Included in Capitation for Pennsylvania (PA) Health Maintenance Organization (HMO) Members","MPPolicyAttachmentInternalSourceId":7126,"PolicyAttachmentPageName":"33d290db-40da-4a2b-b127-7b0176d5d6f8"},} |
