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MASTER BILLING CODE LIST
(Updated January 6, 2008)
Medication Therapy Management Services (MTMS) Codes
Medication Therapy Management Service(s) (MTMS) describe face-to-face patient assessment and intervention as appropriate, by a pharmacist. MTMS is provided to optimize the response to medications or to manage treatment-related medication interactions or complications.
MTMS includes the following documented elements: review of the pertinent patient history, medication profile (prescription and non-prescription), and recommendations for improving health outcomes and treatment compliance. These codes are not to be used to describe the provision of product-specific information at the point of dispensing or any other routine dispensing-related activities.
| Billing Code |
Description |
99605 (New encounter) |
Medication therapy management service(s) provided by a pharmacist, individual, face-to-face with patient, initial 15 minutes, with assessment, and intervention if provided; initial encounter |
99606 (Subsequent encounter) |
Subsequent encounter |
99607 (Add on) |
Each additional 15 minutes |
(List separately in addition to code for the primary service)
(Use 99607 in conjunction with 99605, 99606)
Rationale of MTMS Codes
Three codes 99605, 99606, and add-on code 99607 and guidelines have been established to report the provision of medication therapy management services (MTMS). These services are provided by a pharmacist to optimize the response to medications or for the management of treatment-related medication problems or complications. MTM services are initiated at the request of the patient and/or caregiver, payer, pharmacist and/or other healthcare provider. These codes are not to be used to describe the provision of product-specific information (i.e., product information leaflets) at the point of dispensing or any other routine dispensing-related activities (i.e., professional time related to preparation or delivery of the medication).
In provision of MTMS the review of the pertinent patient history, medication profile will include: evaluation of prescription medications, OTC's, and herbal medications, and/or physician samples. The pharmacist will inventory the medication list to identify and/or resolve drug therapy problems such as duplications, under- or overdosing, and drug interactions or other types of therapy related issues. The pharmacist may discover medications that need to be added or stopped. This service may include communication of management recommendations to the prescriber.
Each medication is assessed to determine the effectiveness and the side-effects. A follow-up monitoring call is included in MTMS to determine if symptoms are resolving, if the patient is experiencing side effects, and to assess compliance.
Assessment will be performed to determine the patient's adherence to medication recommendations. The pharmacist will educate the patient and monitor reaction to new and changed prescriptions and over-the-counter (OTC) medications.
Similar to other codes series in the CPT codebook, these codes have been structured to report the initial and more intensive encounter service with code 99605. The subsequent encounter, reported with code 99606 is intended to be reported for services provided which are similar to the initial encounter, with an emphasis on updating information provided at the initial encounter, assessment of the patient compliance and reactions and further evaluation of medications which have been added to the patient's therapy with those previously assessed. Add-on code 99607 is reported in addition to codes 99605, 99606 for each additional fifteen minutes of service beyond the initial service.
Clinical Vignettes for MTMS Codes
99605:
A 66 year-old female with pre-existing osteoporosis has been diagnosed with type 2 diabetes and hyperlipidemia. Initial medication therapy assessment and intervention is performed.
Pre Service
Obtaining patient intake information, gathering or preparing materials that will be used during the patient encounter and coordination of other support staff.
Intra Service
Assessment of the patient may include: obtaining a patient medical and medication (e.g., prescription and non-prescription) history; determining appropriateness of medication therapy (supra- or sub- optimal), performing a review of relevant systems; evaluating pertinent lab data; assessing potential or existing drug-drug, drug-disease, and drug-nutrient interactions; establishing and/or obtaining such additional information (e.g., obtaining information from other medical records) as may be necessary; and development of a care plan including recommendations for optimizing medication therapy.
Pharmacist interventions may include: providing education, training and resources; administering medication; formulating a treatment and/or follow-up plan; providing recommendations for disease prevention; and evaluating the patient's knowledge of medication and willingness to implement recommendations.
Post Service
Documentation of the patient encounter; non face-to-face interventions and recommendations; referrals; communication with other healthcare professionals; administrative functions (including patient and family communications) relative to the patient's care; and as appropriate scheduling of follow-up appointment(s).
99606:
A 66-year-old female with osteoporosis, type 2 diabetes, and hyperlipidemia is receiving follow-up reassessment after receiving a prior medication therapy management service.
Pre Service
Obtaining patient intake information, gathering or preparing materials that will be used during the patient encounter and coordination of other support staff.
Intra Service
Assessment of the patient may include: obtaining or updating a patient medical and medication (prescription and non-prescription) history; performing reviews of relevant systems; reviewing pertinent lab data; assessing potential or existing drug-drug, drug-disease, and drug-nutrient interactions; evaluating medication-related adverse events and toxicities; assessing medication effectiveness, organizing and interpreting the data; establishing and/or obtaining such additional information (e.g., obtaining information from other medical records) as may be necessary; assessing any recent change in medication therapy or a new medication therapy-related problem; developing a care plan including recommendations for optimizing medication therapy.
Pharmacist interventions may include: providing reinforcement of education, training and resources; modifying therapy; administering medication; formulating a treatment and/or follow-up plan; providing recommendations for disease prevention; re-evaluating the patient's knowledge of medication; and evaluating knowledge and willingness to follow new recommendations.
Post Service
Documentation of the patient encounter interventions and recommendations; referrals; communication with other healthcare professionals; administrative functions (including patient and family communications) relative to the patient's care, and as appropriate scheduling of follow-up appointment(s).
99607:
Intra Service
The service(s) continued for an additional 15 minutes with the same patient.
Category I Codes - describes procedures or services rendered by a healthcare professional
Evaluation and Management Codes
| Billing Code |
Description |
Clinical Example |
Category |
99201 |
Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components:
A problem focused history;
A problem focused examination; and
Straightforward medical decision-making.
Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.
Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with patient and/or family. |
1) Initial office visit for the evaluation and management of insect bites from summer camp.
2) Patient comes in with poison ivy: Give explanation on how to manage discomfort and prevent spread. Show products that can be used for relief. |
Office or other outpatient visit |
99202 |
Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components:
an expanded problem focused history;
an expanded problem focused examination; and straightforward medical decision-making.
Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.
Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with patient and/or family. |
1) Initial office visit for a 28-year-old female for the evaluation and management of recurrent vaginal candidiasis
2) Patient comes in the pharmacy with a prescription for an Abuterol MDI. Patient claims that the inhaler that the Dr gave him as a sample isn't working. Sit down with patient and discuss inhaler technique and demonstrate, when finished have patient go through technique. |
Office or other outpatient visit |
| 99203 |
Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components:
a detailed history;
a detailed examination; and
medical decision-making of low complexity.
Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.
Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with patient and/or family. |
1) Initial office visit for a 16-year-old football player with 2-day old acute ankle injury; now with swelling and pain.
2) Patient comes in and would like to speak to pharmacist about his blood pressure. Would like the pharmacist to take BP because he feels the machines are not accurate. Also would like to discuss strategies for keeping BP under control |
Office or other outpatient visit |
| 99204 |
Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components:
a comprehensive history;
a comprehensive examination; and
medical decision-making of moderate complexity.
Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.
Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with patient and/or family. |
1) Initial office visit for the evaluation of a 56-year-old male with shortness of breath upon exertion.
2) Patient comes in who is inquiring about osteoporosis. You take a measurement with your bone density machine. She is concerned about the results so you offer tips about lifestyle mods and diet changes. May suggest physician visit. |
Office or other outpatient visit |
| 99205 |
Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components:
a comprehensive history;
a comprehensive examination; and
medical decision-making of high complexity.
Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.
Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with patient and/or family. |
1) Initial office visit for a 38-year-old female with a family history of breast cancer that presents with a mass in the breast for the management of the nausea and vomiting side effects of chemotherapy
2) Pt newly diagnosed with DM. Help with pick of best glucose meter for pt and how to use. Discuss lifestyle/diet mods along with other tips to help keep pt healthy. Advise on how to draw insulin if necessary (offer products to aid the visually impaired) |
Office or other outpatient visit |
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services. |
1) Office visit for a 25-year-old female, established patient, for a Depo-Provera injection.
2) Patient comes in with warts on their hands. Discuss possible options, explain how to use, etc. |
Office or other outpatient visit |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components:
a problem focused history;
a problem focused examination; and
straightforward medical decision-making.
Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.
Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with patient and/or family. |
1) Office visit for a 19-year-old male, established patient, for management of dandruff
2) Patient comes in with yeast infection. Inquire about past history of infections. Discuss which product used in past/which ones worked. If recurrent may need physician visit and prescription med. |
Office or other outpatient visit |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components:
an expanded problem focused history;
an expanded problem focused examination; and
medical decision-making of low complexity.
Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.
Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with patient and/or family. |
1) Office visit for a 63-year-old male, established patient with stable COPD for management of medications
2) Pt is going on trip to Africa. Wants info on how to avoid getting sick (malaria, dysentery, etc), and what to do if it does happen. Discuss importance of eating fully cooked foods and bottled water. If sick, stress hydration and proper use of Imodium. Suggest speaking to Dr. about possible infection prophylaxis. |
Office or other outpatient visit |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components:
a detailed history;
a detailed examination; and
medical decision-making of moderate complexity.
Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.
Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with patient and/or family.
|
1) Evaluation and management for a 32-year-old female, established patient, with a new onset of diabetes
2) Smoking cessation consult. Discuss prior attempts to quit. Help decide best product for pt. Provide tips on how to eliminate triggers and the need to get support from family and friends. Help them to set a "quit date". Have them call any time with questions and/or concerns. Set follow up date to monitor progress. |
Office or other outpatient visit |
| 99215 |
Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components:
a comprehensive history;
a comprehensive examination; and
medical decision-making of high complexity.
Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.
Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with patient and/or family. |
1) Office visit for a 54-year-old female with MS (multiple sclerosis) that can no longer ambulate for an evaluation for a wheelchair
2) Patient comes in to speak with you about her BP. You sit down to help take her BP and should inquires about cholesterol monitoring. You take a sample of her blood and run a test. It is high so you give her a rundown of possible treatment options and the consequences of health issues that can come if not addressed. |
Office or other outpatient visit |
| 99241 |
Office consultation for a new or established patient, which requires these three components:
a problem focused history;
a problem focused examination; and
straightforward medical decision-making.
Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.
Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 15 minutes face-to-face with patient and/or family. |
1) Office consultation with a 86-year-old male with progressive hearing loss for evaluation for a hearing aid.
2) Patient has a problem with reoccurring acne. Wants advise about OTC and non pharmacologic treatment. Also discuss diet mods. Pt is also wondering about Accutane (consult on pros and cons, and things pt will have to do if female) |
Office and Other Outpatient Consultations |
| 99242 |
Office consultation for a new or established patient, which requires these three components:
an expanded problem focused history;
an expanded problem focused examination; and
straightforward medical decision-making.
Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.
Usually, the presenting problem(s) are of low severity. Physicians typically spend 30 minutes face-to-face with patient and/or family. |
1) Office consultation with a 54-year-old female, referred for follow-up of HbA1C and evaluation of dosage adjustment |
Office and Other Outpatient Consultations |
| 99243 |
Office consultation for a new or established patient, which requires these three components:
a detailed history;
a detailed examination; and
medical decision-making of low complexity.
Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.
Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 40 minutes face-to-face with patient and/or family. |
1) Office consultation with a 22-year-old female with IBS not responding to therapy.
2) A patient is going to be beginning chemotherapy for breast cancer. You sit her down and explain what the meds are going to do, how they work, all of the things that she should expect and things that she should do to avoid infection. A very extensive counseling and question session. |
Office and Other Outpatient Consultations |
| 99244 |
Office consultation for a new or established patient, which requires these three components:
a comprehensive history;
a comprehensive examination; and medical decision-making of moderate complexity.
Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.
Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with patient and/or family. |
1) Office consultation for a patient that failed a knee arthroscopy with pain upon walking to discuss further options
2) Patient comes in after their physician wrote them a prescription for coumadin. You are going to be doing the INR monitoring and the dose changes to get then stable. Counseling about the drug is extensive. |
Office and Other Outpatient Consultations |
| 99245 |
Office consultation for a new or established patient, which requires these three components:
a comprehensive history;
a comprehensive examination; and
medical decision-making of high complexity.
Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.
Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 80 minutes face-to-face with patient and/or family. |
1) Office consultation in the emergency room for a 17-year-old male with severe head trauma |
Office and Other Outpatient Consultations |
| 99371 |
Telephone call by a physician to patient or for consultation or medical management or for coordinating medical management with other health care professionals (eg, nurses, therapists, social workers, nutritionists, physicians, pharmacists); simple or brief (eg, to report on tests and/or laboratory results, to clarify or alter previous instructions, to integrate new information from other health professionals into the medical treatment plan, or to adjust therapy) |
1) To make a call to a patient to change the directions on medication dosage
2) Calling the physicians office to verify that a pts WBC is in the normal range before dispensing clozapine |
Evaluation and Management, Case Management Services, Telephone Calls |
| 99372 |
Telephone call by a physician to patient or for consultation or medical management or for coordinating medical management with other health care professionals (eg, nurses, therapists, social workers, nutritionists, physicians, pharmacists); intermediate (eg, to provide advice to an established patient on a new problem, to initiate therapy that can be handled by telephone, to discuss test results in detail, to coordinate medical management of a new problem in an established patient, to discuss and evaluate new information and details, or to initiate new plan of care) |
1) To make a call to a patient to discuss the results of a lipid panel. |
Evaluation and Management, Case Management Services, Telephone Calls |
| 99373 |
Telephone call by a physician to patient or for consultation or medical management or for coordinating medical management with other health care professionals (eg, nurses, therapists, social workers, nutritionists, physicians, pharmacists); complex or lengthy (eg, lengthy counseling session with anxious or distraught patient, detailed or prolonged discussion with family members regarding seriously ill patient, lengthy communication necessary to coordinate complex services of several different health professionals working on different aspects of the total patient care plan) |
1) To make a call to a patient to discuss hospice. |
Evaluation and Management, Case Management Services, Telephone Calls |
99381 |
Initial comprehensive preventative medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunizations(s), laboratory/diagnostic procedures, new patient, infant (age under 1 year). |
|
Preventative Medicine Services |
99382 |
Initial comprehensive preventative medicine, new patient, early childhood (age 1 - 4 years). |
1) A 2-year-old, new patient that requires immunizations |
Preventative Medicine Services |
99383 |
Initial comprehensive preventative medicine, new patient, late childhood (age 5 - 11 years). |
|
Preventative Medicine Services |
| 99384 |
Initial comprehensive preventative medicine, new patient, adolescent (age 12 - 17 years). |
|
Preventative Medicine Services |
| 99385 |
Initial comprehensive preventative medicine, new patient, age 18 - 39 years. |
|
Preventative Medicine Services |
| 99386 |
Initial comprehensive preventative medicine, new patient, age 40 - 64 years. |
|
Preventative Medicine Services |
| 99387 |
Initial comprehensive preventative medicine, new patient, age 65 years and older. |
1) A 75-year-old new patient that requires a flu vaccine |
Preventative Medicine Services |
99391 |
Periodic comprehensive preventative medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunizations(s), laboratory/diagnostic procedures, established patient, infant (age under 1 year). |
|
Preventative Medicine Services |
99392 |
Periodic comprehensive preventative medicine, established patient, early childhood (age 1 - 4 years). |
|
Preventative Medicine Services |
99393 |
Periodic comprehensive preventative medicine, established patient, late childhood (age 5 - 11 years). |
|
Preventative Medicine Services |
| 99394 |
Periodic comprehensive preventative medicine, established patient, adolescent (age 12 - 17 years). |
|
Preventative Medicine Services |
| 99395 |
Periodic comprehensive preventative medicine, established patient, age 18 - 39 years. |
|
Preventative Medicine Services |
| 99396 |
Periodic comprehensive preventative medicine, established patient, age 40 - 64 years. |
|
Preventative Medicine Services |
| 99397 |
Periodic comprehensive preventative medicine, established patient, age 65 years and older. |
|
Preventative Medicine Services |
| 99401 |
Preventative medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes. |
|
Preventative Medicine, Individual Counseling |
| 99402 |
Preventative medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes. |
|
Preventative Medicine, Individual Counseling |
| 99403 |
Preventative medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 45 minutes. |
|
Preventative Medicine, Individual Counseling |
| 99404 |
Preventative medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 60 minutes. |
|
Preventative Medicine, Individual Counseling |
99411 |
Preventative medicine counseling and/or risk factor reduction intervention(s) provided to individuals in a group setting (separate procedure); approximately 30 minutes. |
|
Preventative Medicine, Group Counseling |
99412 |
Preventative medicine counseling and/or risk factor reduction intervention(s) provided to individuals in a group setting (separate procedure); approximately 60 minutes. |
Diabetes education group consulting |
Preventative Medicine, Group Counseling |
| 99420 |
Administration and interpretation of health risk assessment instrument (e.g. health hazard appraisal). |
|
Other Preventative Medicine Services |
| 99429 |
Unlisted preventative medicine service - use when a preventative medicine service is provided that is not currently listed in CPT. When reporting such a service, you may need to include a "Special Report." A special report demonstrates the medical appropriateness of the service. Pertinent information should include an adequate definition or description of the nature, extent, and need for the procedure; and the time, effort, and equipment necessary to provide this service. Additional items, which may be included, are complexity of symptoms, final diagnosis, pertinent physical findings, diagnostic and therapeutic procedures, concurrent problems, and follow-up care. |
|
Other Preventative Medicine Services |
| 99499 |
Unlisted evaluation and management service- use when an evaluation and management service is provided that is not currently listed in CPT. When reporting such a service, you may need to include a "Special Report." A special report demonstrates the medical appropriateness of the service. Pertinent information should include an adequate definition or description of the nature, extent, and need for the procedure; and the time, effort, and equipment necessary to provide this service. Additional items, which may be included, are complexity of symptoms, final diagnosis, pertinent physical findings, diagnostic and therapeutic procedures, concurrent problems, and follow-up care. |
|
Other Evaluation and Management Services |
Other Category I Codes - (*) designates new codes added since last distribution of the master billing code list.
| Billing Code |
Description |
Clinical Example |
Category |
| 36415 |
Collection of venous blood by venipuncture |
|
Surgery/ Cardiovascular/
Venous
|
36416 |
Venipuncture, needle or catheter for diagnostic study or intravenous therapy, percutaneous - Collection of capillary blood specimen (eg, finger, heel, ear stick) |
|
Surgery/ Cardiovascular/
Venous
|
76977 |
Other procedures - ultrasound bone density measurement and interpretation, peripheral site(s), any method |
|
Radiology/ Diagnostic Ultrasound |
80061 |
Lipid panel. This panel must include the following:
Cholesterol, serum, total (82465)
Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol) (83718)
Triglycerides (84478) |
|
Pathology and Laboratory/Organ or Disease Oriented Panels |
80500 |
Clinical pathology consultation; limited, without review of patient's history and medical records |
|
Pathology and Laboratory/ Consultations (Clinical Pathology) |
80502 |
Clinical pathology consultation; comprehensive, for a complex diagnostic problem, with review of patient's history and medical records |
|
Pathology and Laboratory/ Consultations (Clinical Pathology) |
81025 |
Urine pregnancy test, by visual color comparison methods |
|
Pathology and Laboratory/ Urinalysis |
82270 |
Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations |
|
Pathology and Laboratory/ Chemistry |
82465 |
Cholesterol, serum or whole blood, total |
|
Pathology and Laboratory/ Chemistry |
82947 |
Glucose, quantitative, blood (except reagent strip) |
|
Pathology and Laboratory/ Chemistry |
82948 |
Glucose, quantitative, blood, reagent strip |
|
Pathology and Laboratory/ Chemistry |
82953 |
Glucose, blood by glucose monitoring device(s) cleared by the FDA specifically for home use |
|
Pathology and Laboratory/ Chemistry |
83013 |
Helicobacter pylori; analysis for urease activity, non-radioactive isotope |
|
Pathology and Laboratory/ Chemistry |
83036 |
Hemoglobin, by copper sulfate method, non-automated, glycated |
|
Pathology and Laboratory/ Chemistry |
83718 |
Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol) |
|
Pathology and Laboratory/ Chemistry |
84450 |
Transferase; aspartate amino (AST) (SGOT) |
|
Pathology and Laboratory/ Chemistry |
84460 |
Transferase; alanine amino (ALT) (SGPT) |
|
Pathology and Laboratory/ Chemistry |
84478 |
Triglycerides |
|
Pathology and Laboratory/ Chemistry |
85610 |
Prothrombin time |
|
Pathology and Laboratory/ Hematology and Coagulation |
87880 |
Infectious agent detection by immunoassay with direct optical observation, Streptococcus, group A |
|
Pathology and Laboratory/ Microbiology |
90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, intramuscular, and jet injections); one vaccine (single of combination vaccine/toxoid) |
|
Medicine/
Immunization Administration for Vaccines/Toxins
|
90472 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, intramuscular, and jet injections); each additional vaccine (single of combination vaccine/toxoid) (List separately in addition to code for primary procedure) |
|
Medicine/
Immunization Administration for Vaccines/Toxins
|
90632 |
Hepatitis A vaccine, adult dosage, for intramuscular use |
|
Medicine/
Vaccines, Toxoids
|
90657 |
Influenza virus vaccine, split virus, for children 6-35 months of age, for intramuscular use |
|
Medicine/
Vaccines, Toxoids
|
90658 |
Influenza virus vaccine, split virus, for individuals 3 years of age and above, for intramuscular use |
|
Medicine/
Vaccines, Toxoids
|
90659 |
Influenza virus vaccine, whole virus, for intramuscular or jet injection use |
|
Medicine/
Vaccines, Toxoids
|
90660 |
Influenza virus vaccine, live, for intranasal use |
|
Medicine/
Vaccines, Toxoids
|
90707 |
Measles, mumps, rubella virus vaccine (MMR), live, for subcutaneous use |
|
Medicine/
Vaccines, Toxoids
|
90712 |
Poliovirus vaccine, (any type(s))(OPV), live, for oral use |
|
Medicine/
Vaccines, Toxoids
|
90716 |
Varicella virus vaccine, live, for subcutaneous use |
|
Medicine/
Vaccines, Toxoids
|
90718 |
Tetanus and diphtheria toxoids (Td) adsorbed for use in individuals seven years or older, for intramuscular use |
|
Medicine/
Vaccines, Toxoids
|
90732 |
Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, for use in individuals 2 years or older, for subcutaneous or intramuscular use |
|
Medicine/
Vaccines, Toxoids
|
90745 |
Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use |
|
Medicine/
Vaccines, Toxoids
|
94010 |
Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation |
|
Medicine/
Pulmonary
|
94750 |
Pulmonary compliance study (eg, plethysmography, volume and pressure measurements) |
|
Medicine/
Pulmonary
|
95926 |
Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in lower limbs |
Diabetic foot exams using monofilament |
Medicine/Neurology and Neuromuscular Procedures |
97535 |
Self-care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact by provider, each minutes |
|
Medicine/
Therapeutic Procedures
|
| 98960 |
Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes, individual patient |
|
Education and Training for Patient Self Management |
| 98961 |
Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes, 2-4 patients |
|
Education and Training for Patient Self Management |
| 96962 |
Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes, 5-8 patients |
|
Education and Training for Patient Self Management |
99050 |
Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (eg. Holidays, Saturday or Sunday), in addition to basic services |
|
Medicine/Special Services, Procedures and Reports |
| 99080 |
Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form |
|
Medicine/Special Services, Procedures and Reports |
| 99090 |
Analysis of clinical data stored in computers (eg. ECGs, blood pressures, hematologic data)
(For physician/health care professional collection and interpretation of physiologic data stored/transmitted by patient/caregiver, see 99091)
(Do not report 99090 if other more specific CPT codes exist, eg. 93014, 93227, 93233, 93272 for cardiographic services; 95250 for continuous glucose monitoring, 97750 for musculoskeletal function testing) |
|
Medicine/Special Services, Procedures and Reports |
| 99091 |
Collection and interpretation of physiologic data (eg. ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, requiring a minimum of 30 minutes of time |
|
Medicine/Special Services, Procedures and Reports |
99071 |
Educational supplies, such as books, tapes, and pamphlets for a patient's education at a cost to the provider |
|
Medicine/Special Services, Procedures and Reports |
82570 |
Creatinine; other source |
|
Pathology and Laboratory, Chemistry |
Category II Codes - These codes are intended to facilitate data collection by coding certain services and/or test results that are agreed upon as contributing to positive health outcomes and quality patient care. As a result, these codes are used as tracking codes for performance measurement. These codes describe components that are typically included in an evaluation and management service or test results that are part of the laboratory test/procedure. Consequently, they do not have a relative value associated with them. These codes are not required for correct coding and may not be used as a substitute for category I codes.
Billing Code |
Description |
Performance Measurement Set |
0001F |
Blood pressure, measured |
Chronic Stable Coronary Artery Disease (CAD) |
0002F |
Tobacco use, smoking, assessed |
Preventative Care and Screening Physician Performance Measurement Set |
0003F |
Tobacco use, non-smoking, assessed |
Preventative Care and Screening Physician Performance Measurement Set |
0004F |
Tobacco use cessation intervention, counseling |
Preventative Care and Screening Physician Performance Measurement Set |
0009F |
Anginal symptoms and level of activity, assessed |
Chronic Stable Coronary Artery Disease (CAD) |
Modifiers
Modifier |
Type of Service |
Description |
21 |
Prolonged Evaluation and Management Services |
When the face-to-face or floor/unit service(s) provided is prolonged or otherwise greater than that usually required for the highest level of evaluation and management service within a given category, it may be identified by adding modifier '21' to the evaluation and management code number. A report may also be appropriate. |
22 |
Unusual Procedural Services |
When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier '22' to the usual procedure number. A report may also be appropriate. |
| 32 |
Mandated Services |
Services related to mandated consultation and/or related services (eg, PRO, third party payer, governmental, legislative or regulatory requirement) may be identified by adding the modifier '32' to the basic procedure. A relevant pharmacy example is pharmacist counseling which is mandated by a Board of Pharmacy as a result of OBRA '90. |
| 76 |
Repeat Procedure by Same Physician |
The physician may need to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance may be reported by adding the modifier '76' to the repeated procedure/service. |
77 |
Repeat Procedure by Another Physician |
The physician may need to indicate that a basic procedure or service performed by another physician had to be repeated. This circumstance may be reported by adding the modifier '77' to the repeated procedure/service. |
91 |
Repeat Clinical Diagnostic Laboratory Test |
In the course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results. Under these circumstances, the laboratory tests performed can be identified by its usual procedure number and the addition of the modifier '91'. Note: This modifier may not be used when tests are rerun to confirm initial test results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required. This modifier may not be used when other code(s) describe a series of test results (eg, glucose tolerance tests, evocative/suppression testing). This modifier may only be used for laboratory test(s) performed more than once on the same day on the same patient. |
99 |
Multiple Modifiers |
Under certain circumstances, two or more modifiers may be necessary to completely delineate a service. In such situations modifier '99' should be added to the basic procedure, and other applicable modifiers may be listed as part of the description of the service. |
Point of Service Codes - used on professional claims to specify the entity where service(s) were rendered. Maintained by the Centers for Medicare and Medicaid Services (CMS).
| *01 - Pharmacy
A facility or location where drugs and other medically related items and services are sold, dispensed, or otherwise provided directly to patients. |
| 02 Unassigned |
| 03 - School
A facility whose primary purpose is education. |
| 04 - Homeless Shelter
A facility or location whose primary purpose is to provide temporary housing to homeless individuals (e.g., emergency shelters, individual or family shelters). (See note below.) |
| 05 - Indian Health Service Free-Standing Facility
A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to American Indians and Alaska Natives who do not require hospitalization. (See note below.) |
| 06 - Indian Health Service Provider-Based Facility
A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services rendered by, or under the supervision of, physicians to American Indians and Alaska Natives admitted as inpatients or outpatients. (See note below.) |
| 07 - Tribal 638 Free-Standing Facility
A facility or location owned and operated by a federally Recognized American Indian or Alaska Native tribe or Tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation services to tribal members who do not require hospitalization. (See note below.) |
| 08 - Tribal 638 Provider-Based Facility
A facility or location owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation services to tribal members admitted as inpatients or outpatients. (See note below.) |
| 09-10 Unassigned |
| 11 - Office
Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis. |
| 12 - Home
Location, other than a hospital or other facility, where the patient receives care in a private residence. |
| 13 - Assisted Living Facility
Congregate residential facility with self-contained living units providing assessment of each resident's needs and on-site support 24 hours a day, seven days a week, with the capacity to deliver or arrange for services including some health care and other services. |
| 14 - Group Home
Congregate residential foster care setting for children and adolescents in state custody that provides some social, health care, and educational support services and that promotes rehabilitation and reintegration of residents into the community. |
| 15 - Mobile Unit
A facility/unit that moves from place-to-place equipped to provide preventive, screening, diagnostic, and/or treatment services. |
| 16-19 Unassigned |
| 20 - Urgent Care Facility
Location, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention. |
| 21 - Inpatient Hospital
A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions. |
| 22 - Outpatient Hospital
A portion of a hospital which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. |
| 23 - Emergency Room - Hospital
A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided. |
| 24 - Ambulatory Surgical Center
A freestanding facility, other than a physician's office, where surgical and diagnostic services are provided on an ambulatory basis. |
| 25 - Birthing Center
A facility, other than a hospital's maternity facilities or a physician's office, which provides a setting for labor, delivery, and immediate postpartum care as well as immediate care of newborn infants. |
| 26 - Military Treatment Facility
A medical facility operated by one or more of the Uniformed Services. Military Treatment Facility (MTF) also refers to certain former U.S. Public Health Service (USPHS) facilities now designated as Uniformed Service Treatment Facilities (USTF). |
| 27-30 Unassigned |
| 31 - Skilled Nursing Facility
A facility, which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services, but does not provide the level of care or treatment available in a hospital. |
| 32 - Nursing Facility
A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than mentally retarded individuals. |
| 33 - Custodial Care Facility
A facility which provides room, board and other personal assistance services, generally on a long-term basis, and which does not include a medical component. |
| 34 - Hospice
A facility, other than a patient's home, in which palliative and supportive care for terminally ill patients and their families are provided. |
| 35-40 Unassigned |
| 41 - Ambulance - Land
A land vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured. |
| 42 - Ambulance - Air or Water
An air or water vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured. |
| 43-48 Unassigned |
| 49 - Independent Clinic
A location, not part of a hospital and not described by any other place of service code, that is organized and operated to provide preventive, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only. |
| 50 - Federally Qualified Health Center
A facility located in a medically underserved area that provides Medicare beneficiaries preventive primary medical care under the general direction of a physician. |
| 51 - Inpatient Psychiatric Facility
A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician. |
| 52 - Psychiatric Facility - Partial Hospitalization
A facility for the diagnosis and treatment of mental illness that provides a planned therapeutic program for patients who do not require full time hospitalization, but who need broader programs than are possible from outpatient visits to a hospital-based or hospital-affiliated facility. |
| 53 - Community Mental Health Center
A facility that provides the following services: outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically ill, and residents of the CMHC's mental health services area who have been discharged from inpatient treatment at a mental health facility; 24 hour a day emergency care services; day treatment, other partial hospitalization services, or psychosocial rehabilitation services; screening for patients being considered for admission to State mental health facilities to determine the appropriateness of such admission; and consultation and education services. |
| 54 - Intermediate Care Facility/Mentally Retarded
A facility, which primarily provides health-related care and services above the level of custodial care to mentally retarded individuals, but does not provide the level of care or treatment available in a hospital or SNF. |
| 55 - Residential Substance Abuse Treatment Facility
A facility which provides treatment for substance (alcohol and drug) abuse to live-in residents who do not require acute medical care. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, psychological testing, and room and board. |
| 56 - Psychiatric Residential Treatment Center
A facility or distinct part of a facility for psychiatric care which provides a total 24-hour therapeutically planned and professionally staffed group living and learning environment. |
| 57 - Non-Residential Substance Abuse Treatment Facility
A location which provides treatment for substance (alcohol and drug) abuse on an ambulatory basis. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, and psychological testing. |
| 58-59 Unassigned |
| 60 - Mass Immunization Center
A location where providers administer pneumococcal pneumonia and influenza virus vaccinations and submit these services as electronic media claims, paper claims, or using the roster billing method. This generally takes place in a mass immunization setting, such as, a public health center, pharmacy, or mall but may include a physician office setting. |
| 61 - Comprehensive Inpatient Rehabilitation Facility
A facility that provides comprehensive rehabilitation services under the supervision of a physician to inpatients with physical disabilities. Services include physical therapy, occupational therapy, speech pathology, social or psychological services, and orthotics and prosthetics services. |
| 62 - Comprehensive Outpatient Rehabilitation Facility
A facility that provides comprehensive rehabilitation services under the supervision of a physician to outpatients with physical disabilities. Services include physical therapy, occupational therapy, and speech pathology services. |
| 63-64 Unassigned |
| 65 - End-Stage Renal Disease Treatment Facility
A facility other than a hospital, which provides dialysis treatment, maintenance, and/or training to patients or caregivers on an ambulatory or home-care basis. |
| 66-70 Unassigned |
| 71 - State or Local Public Health Clinic
A facility maintained by either State or local health departments that provides ambulatory primary medical care under the general direction of a physician. |
| 72 - Rural Health Clinic
A certified facility which is located in a rural medically underserved area that provides ambulatory primary medical care under the general direction of a physician. |
| 73-80 Unassigned |
| 81 - Independent Laboratory
A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician's office. |
| 82-98 Unassigned |
| 99 - Other Place of Service
Other place of service not identified above. |
Healthcare Common Procedure Coding System (HCPCS) Codes - used primarily to identify products, supplies, and services not included in the CPT codes. (*) designates new codes added since last distribution of the master billing code list.
| HCPCS Procedure Code |
Procedure |
Pharmacy / Clinical Example |
| A4230 |
Infusion set for external insulin pump, non needle cannula type |
|
| A4231 |
Infusion set for external insulin pump, needle type |
|
| A4232 |
Syringe with needle for external insulin pump, sterile 3cc |
|
| A4244 |
Alcohol per pint |
|
| A4250 |
Urine test or reagent strips or tablets (100 tablets or strips) |
|
| A4253 |
Blood glucose test or reagents strips for home blood glucose monitor, per 50 strips |
|
| A4254 |
Replacement battery any type, for use w/ medically necessary home blood glucose monitor owned by patient, each |
|
| A4256 |
Normal, low and high calibrator solutions/chips pkg |
|
| A4258 |
Spring Powered Device for Lancet, each |
|
| A4259 |
Lancets, per box of 100 |
|
A5500 |
For diabetics only, fitting (including follow-up) custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe |
|
A5501 |
For diabetics only, fitting (including follow-up) custom preparation and supply of shoe molded form cast(s) of patient's foot (custom molded shoe), per shoe |
|
A5503 |
For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with roller or rigid rocker bottom, per shoe |
|
A5504 |
For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with wedge(s), per shoe |
|
A5505 |
For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with metatarsal bar, per shoe |
|
A5506 |
For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with off-set heel(s), per shoe |
|
A5507 |
For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe, per shoe |
|
A5508 |
For diabetics only, deluxe feature of off-the-shelf depth-inlay shoe or custom-molded shoe, per shoe |
|
A5509 |
For diabetics only, direct formed, molded to foot with external heat source (i.e., heat gun) multiple density insert(s), prefabricated, per shoe |
|
A5510 |
For diabetics only, direct formed, compression molded to patient's foot without external heat source, multiple-density insert(s) prefabricated, per shoe |
|
A5511 |
For diabetics only, custom-molded from model of patient's foot, multiple density insert(s), custom-fabricated, per shoe |
|
E0607KS |
Home Blood glucose monitor-Non-Insulin Treated |
|
E0607KX |
Home Blood glucose monitor-Insulin Treated |
|
E0607NU |
Home Blood glucose monitor-New |
|
E2100KS |
Blood glucose monitor with integrated voice synthesizer-Non-Insulin Treated |
|
E2100KX |
Blood glucose monitor with integrated voice synthesizer-Insulin Treated |
|
E2100NU |
Blood glucose monitor with integrated voice synthesizer-New |
|
G0001 |
Routine venipuncture for collection of specimen(s) [Previously listed as Routine Finger Stick (Medicare only) |
|
G0008 |
Immunization Administration (Medicare only). Note: also use in conjunction with HCPCS code for vaccine product. |
|
| G0009 |
Administration of pneumococcal vaccine when no physician fee schedule service on the same day |
|
| G0010 |
Administration of hepatitis B vaccine when no physician fee schedule service on the same day |
|
| G0108 |
Diabetes outpatient self management training services, individual session, per 30 minutes of training (Medicare only) |
|
| G0109 |
Diabetes outpatient self management training services, group session, per 30 minutes of training (Medicare only) |
|
| G0175 |
Scheduled interdisciplinary team conference (minimum of three exclusive of patient care nursing staff) with patient present |
|
|
