Nurse Practitioner Procedure Codes Version 2021-2 Page 3 of 64 GENERAL INFORMATION 1. MULTIPLE CALLS: If an individual patient is seen on more than one occasion during a single day, the fee for each visit may be allowed.
Nurse Practitioner Procedure Codes Version 2021-2 Page 5 of 64 11. DVS AUTHORIZATION (#): Codes followed by # require an authorization via the dispensing validation system (DVS) before services are rendered.
NEW YORK STATE MEDICAID PROGRAM NURSE PRACTITIONER PROCEDURE CODES Nurse Practitioner Procedure Codes Table of Contents GENERAL INFORMATION ........................................................................................ 3 SERVICES PROVIDED IN ARTICLE 28 FACILITIES .................................................. 5 MMIS MODIFIERS..................................................................................................... 6 MEDICINE SECTION................................................................................................. 8 GENERAL RULES AND INFORMATION................................................................. 8 EVALUATION AND MANAGEMENT CODES ........................................................ 15 LABORATORY SERVICES PERFORMED IN THE OFFICE...................................... 31 DRUGS AND DRUG ADMINISTRATION .................................................................. 32 IMMUNIZATIONS................................................................................................. 32 DRUGS ADMINISTERED OTHER THAN ORAL METHOD .................................... 37 HYDRATION, THERAPEUTIC, PROPHYLACTIC, DIAGNOSTIC INJECTIONS ..... 45 CHEMOTHERAPY DRUGS .................................................................................. 49 PSYCHIATRY.......................................................................................................... 54 SPECIAL OPHTHALMOLOGICAL SERVICES.......................................................... 54 CARDIOVASCULAR................................................................................................ 56 PULMONARY.......................................................................................................... 53 ALLERGY AND CLINICAL IMMUNOLOGY............................................................... 53 MISCELLANEOUS SERVICES ................................................................................ 53 SURGERY SECTION .............................................................................................. 54 GENERAL INFORMATION AND RULES............................................................... 55 INTEGUMENTARY SYSTEM................................................................................ 56 DIGESTIVE SYSTEM ........................................................................................... 57 FEMALE GENITAL SYSTEM ................................................................................ 58 MATERNITY CARE .............................................................................................. 58 NERVOUS SYSTEM ............................................................................................ 59 AUDITORY SYSTEM ........................................................................................... 59 Version 2021-2 Page 2 of 64 Nurse Practitioner Procedure Codes GENERAL INFORMATION 1. MULTIPLE CALLS: If an individual patient is seen on more than one occasion during a single day, the fee for each visit may be allowed. 2. CHARGES FOR DIAGNOSTIC PROCEDURES: Charges for special diagnostic procedures which are not considered to be a routine part of an examination (eg, ECG) are reimbursable in addition to the usual visit fee. 3. SEPARATE PROCEDURE: Certain of the listed procedures are commonly carried out as an integral part of a total service and as such do not warrant a separate charge. When such a procedure is carried out as a separate entity, not immediately related to other services, the indicated value for "Separate Procedure" is applicable. 4. REFERRAL: A referral is the transfer of the total or specific care of a patient from one physician or nurse practitioner to another and does not constitute a consultation. Initial evaluation and subsequent services are designated as listed in LEVELS OF E/M SERVICE. Referral is to be distinguished from consultation. REFERRAL is the transfer of the patient from one practitioner to another for definitive treatment. 5. CONSULTATION: is advice and opinion from an accredited physician specialist called in by the attending practitioner in regard to the further management of the patient by the attending practitioner. Consultation fees are applicable only when examinations are provided by an accredited physician specialist within the scope of his specialty upon request of the authorizing agency or of the attending practitioner who is treating the medical problem for which consultation is required. The attending practitioner must certify that he requested such consultation and that it was incident and necessary to his further care of the patient. When the consultant physician assumes responsibility for a portion of patient management, he will be rendering concurrent care (use appropriate level of evaluation and management codes). If he has had the case transferred or referred to him, he should then use the appropriate codes for services rendered (eg, visits, procedures) on and subsequent to the date of transfer. 6. BY REPORT: A service that is rarely provided, unusual, variable, or new may require a special report in determining 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 the service. Additional items which may be included are: Complexity of symptoms, final diagnosis, pertinent physical findings (such as size, locations, and number of lesions(s), if appropriate), diagnostic and therapeutic procedures (including major and supplementary surgical procedures, if appropriate), concurrent problems, and follow-up care. Version 2021-2 Page 3 of 64 Nurse Practitioner Procedure Codes When the value of a procedure is to be determined "By Report" (BR), information concerning the nature, extent and need for the procedure or service must be furnished in addition to the time, skill and equipment necessitated. Appropriate documentation (eg, procedure description, itemized invoices, etc.) should accompany all claims submitted. Itemized invoices must document acquisition cost, the line item cost from a manufacturer or wholesaler net of any rebates, discounts or other valuable considerations. 7. MATERIALS SUPPLIED BY PRACTITIONER: Supplies and materials provided, eg, sterile trays/drugs, over and above those usually included with the procedure(s), office visit or other services rendered may be listed separately. List drugs, trays, supplies and materials provided. Identify as 99070 or specific supply code. Reimbursement for supplies and material (including drugs, vaccines and immune globulins) furnished by practitioners to their patients is based on the acquisition cost to the practitioner. For all items furnished in this fashion it is expected that the practitioner will maintain auditable records of the actual itemized invoice cost represented on the invoice. New York State Medicaid does not intend to pay more than the acquisition cost, as established by invoice, to the practitioner. Regardless of whether an invoice must be submitted to Medicaid for payment, the practitioner is expected to limit his or her Medicaid claim amount to the actual invoice cost of the item provided. 8. PRESCRIBER WORKSHEET: Enteral formula requires voice interactive telephone prior authorization from the Medicaid program. The prescriber must initiate the authorization through this system. The worksheet specifies the questions asked on the voice interactive telephone system and must be maintained in the patient's clinical record. The worksheet can be found on the Provider Communication link. eMedNY : Provider Manuals : Nurse Practitioner Provider Communications 9. PRIOR APPROVAL: Payment for those listed procedures where the MMIS code number is underlined is dependent upon obtaining the approval of the Department of Health prior to performance of the procedure. If such prior approval is not obtained, no reimbursement will be made. 10. RADIOLOGY PRIOR APPROVAL: Information for Ordering Providers- If you are ordering a CT, CTA, MRI, MRA, Cardiac Nuclear, or PET procedure, you or your office staff are required to obtain an approval number through the RadConsult program. Requests will be reviewed against guidelines, and a prior approval number will be issued. Using a secure login, you will have the ability to access RadConsult Online or call the RadConsult contact center to check the status of procedure requests. Beneficiaries who are eligible for both Medicaid and Medicare (dual eligible) or beneficiaries who are enrolled in a managed care plan are not included. Additional information is available at http://www.emedny.org/ProviderManuals/Radiology/index.html Version 2021-2 Page 4 of 64 Nurse Practitioner Procedure Codes 11. DVS AUTHORIZATION (#): Codes followed by # require an authorization via the dispensing validation system (DVS) before services are rendered. 12. PAYMENT IN FULL: Fees paid in accordance with the allowances in the Medical Fee Schedule shall be considered full payment for services rendered. No additional charge shall be made by a practitioner. 13. FEES: The fees are listed in the Nurse Practitioner Fee Schedule, available at http://www.emedny.org/ProviderManuals/NursePractitioner/index.html Listed fees are the maximum reimbursable Medicaid fees. Fees for the MOMS Program and PPAC Program can be found in the Enhanced Program Fee Schedule. SERVICES PROVIDED IN ARTICLE 28 FACILITIES The professional component for all services provided by a nurse practitioner in an Article 28 hospital outpatient clinic, hospital inpatient setting, emergency department, ambulatory surgery setting and diagnostic and treatment center (D&TC) for Medicaid fee-for-service patients is included in the APG or APR-DRG payment to the facility. Nurse practitioners may not bill Medicaid separately for professional services provided in an Article 28 facility. MMIS MODIFIERS Note: NCCI associated modifiers are recognized for NCCI code pairs/related edits. For additional information please refer to the CMS website: http://www.cms.hhs.gov/NationalCorrectCodInitEd/ Under certain circumstances, the MMIS code identifying a specific procedure or service must be expanded by two additional characters to further define or explain the nature of the procedure. The circumstances under which such further description is required are detailed below along with the appropriate modifiers to be added to the basic code when the particular circumstance applies. -24 Unrelated Evaluation and Management Service by the Same Practitioner during a Postoperative Period: The practitioner may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding the modifier -24 to the appropriate level of E/M service. (Reimbursement will not exceed 100% of the maximum State Medical Fee Schedule amount.) -25 Significant, Separately Identifiable Evaluation and Management Service by the Same Practitioner on the Day of a Procedure: (Effective 10/1/92) The practitioner may need to indicate that on the day a procedure or service identified by an MMIS code was performed, the Version 2021-2 Page 5 of 64 Nurse Practitioner Procedure Codes patient's condition required a significant, separately identifiable E/M service above and beyond the usual preoperative and postoperative care associated with the procedure that was performed. The E/M service may be prompted by the symptom or condition, for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding the modifier -25 to the appropriate level of E/M service. NOTE: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. (Reimbursement will not exceed 100% of the maximum State Medical Fee Schedule amount.) -77 Repeat Procedure by Another Practitioner: The practitioner may need to indicate that a basic procedure performed by another practitioner had to be repeated. This situation may be reported by adding modifier -77 to the repeated service. (Reimbursement will not exceed 100% of the maximum State Medical Fee Schedule amount.) -79 Unrelated Procedure or Service by the Same Practitioner During the Postoperative Period: The practitioner may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using the modifier -79 to the related procedure. (Reimbursement will not exceed 100% of the maximum State Medical Fee Schedule amount.) -EP Child/Teen Health Program (EPSDT Program): Service provided as part of the Medicaid Early Periodic Screening, Diagnosis and Treatment (EPSDT) Program or Child/Teen Health Program will be identified by adding the modifier -EP to the usual procedure number. (Reimbursement will not exceed 100% of the maximum State Medical Fee Schedule amount.) -FP Service Provided as Part of Family Planning Program: All Family Planning Services will be identified by adding the modifier '-FP' to the usual procedure code: number. (Reimbursement will not exceed 100% of the maximum State' Medical Fee Schedule amount.) -SL State Supplied Vaccine: (Used to identify administration of vaccine supplied by the Vaccines for Children Program (VFC) for children under 19 years of age). When administering vaccine supplied by the state (VFC program), you must append modifier SL State Supplied Vaccine to the procedure code number representing the vaccine administered. Omission of this modifier on claims for recipients under 19 years of age will cause your claim to deny. (Reimbursement will not exceed $17.85, the administration fee for the VFC program.) Version 2021-2 Page 6 of 64 Nurse Practitioner Procedure Codes MEDICINE SECTION GENERAL RULES AND INFORMATION 1. PRIMARY CARE: Primary care is first contact care, the type furnished to individuals when they enter the health care system. Primary care is comprehensive in that it deals with a wide range of health problems, diagnosis and modes of treatment. Primary care is continuous in that an ongoing relationship is established with the primary care practitioner who monitors and provides the necessary follow-up care and is coordinated by linking patients with more varied specialized services when needed. Consultations and care provided on referral from another practitioner is not considered primary care. 2. CLASSIFICATION OF EVALUATION AND MANAGEMENT (E/M) SERVICES: The Federal Health Care Finance Administration has mandated that all state Medicaid programs utilize the new Evaluation and Management coding as published in the American Medical Association's CPT. For the first time, a major section has been devoted entirely to E/M services. The new codes are more than a clarification of the old definitions; they represent a new way of classifying the work of practitioners. In particular, they involve far more clinical detail than the old visit codes. For this reason, it is important to treat the new codes as a new system and not make a one-for-one substitution of a new code number for a code number previously used to report a level of service defined as "brief", "limited", "intermediate", etc. The E/M section is divided into broad categories such as office visits, hospital visits and consultations. Most of the categories are further divided into two or more subcategories of E/M services. For example, there are two subcategories of office visits (new patient and established patient) and there are two subcategories of hospital visits (initial and subsequent). The subcategories of E/M services are further classified into levels of E/M services that are identified by specific codes. This classification is important because the nature of practitioner work varies by type of service, place of service, and the patient's status. The basic format of the levels of E/M services is the same for most categories. First, a unique code number is listed. Second, the place and/or type of service is specified, eg, office consultation. Third, the content of the service is defined, eg, comprehensive history and comprehensive examination. (See levels of E/M services following for details on the content of E/M services.) Fourth, the nature of the presenting problem(s) usually associated with a given level is described. Fifth, the time typically required to provide the service is specified. 3. DEFINITIONS OF COMMONLY USED E/M TERMS: Certain key words and phrases are used throughout the E/M section. The following definitions are intended to reduce the potential for differing interpretations and to increase the consistency of reporting. NEW AND ESTABLISHED PATIENT: A new patient is one who has not received any professional services from the practitioner or practitioners working in the same specialty within the same group within the past three years. Version 2021-2 Page 7 of 64 Nurse Practitioner Procedure Codes An established patient is one who has received professional services from the practitioner within the past three years. In the instance where a practitioner is on call for or covering for another practitioner, the patient's encounter will be classified as it would have been by the practitioner who is not available. No distinction is made between new and established patients in the emergency department. E/M services in the emergency department category may be reported for any new or established patient who presents for treatment in the emergency department. CHIEF COMPLAINT: A concise statement describing the symptom, problem, condition, diagnosis or other factor that is the reason for the encounter, usually stated in the patient's words. CONCURRENT CARE: is the provision of similar services, eg, hospital visits, to the same patient by more than one practitioner on the same day. When concurrent care is provided, no special reporting is required. Modifier -75 has been deleted. COUNSELING: Counseling is a discussion with a patient and/or family concerning one or more of the following areas: · diagnostic results, impressions, and/or recommended diagnostic studies; · prognosis; · risks and benefits of management (treatment) options; · instructions for management (treatment) and/or follow-up; · importance of compliance with chosen management (treatment)options; · risk factor reduction; and · patient and family education. FAMILY HISTORY: A review of medical events in the patient's family that includes significant information about: · the health status or cause of death of parents, siblings, and children; · specific diseases related to problems identified in the Chief Complaint or History of the Present Illness, and/or System Review; · diseases of family members which may be hereditary or place the patient at risk. HISTORY OF PRESENT ILLNESS: A chronological description of the development of the patient's present illness from the first sign and/or symptom to the present. This includes a description of location, quality, severity, timing, context, modifying factors and associated signs and symptoms significantly related to the presenting problem(s). NATURE OF PRESENTING PROBLEM: A presenting problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for encounter, with or without a diagnosis being established at the time of the encounter. The E/M codes recognize five types of presenting problems that are defined as follows: · Minimal A problem that may not require the presence of the practitioner, but service is provided under the practitioner's supervision. · Self-limited or Minor A problem that runs a definite and prescribed course, is transient in nature and is not likely to permanently alter health status OR has a good prognosis with management/compliance. Version 2021-2 Page 8 of 64 Nurse Practitioner Procedure Codes · Low severity A problem where the risk of morbidity without treatment is low; there is little to no risk of mortality without treatment; full recovery without functional impairment is expected. · Moderate severity A problem where the risk of morbidity without treatment is moderate; there is moderate risk of mortality without treatment; uncertain prognosis OR increased probability of prolonged functional impairment. · High severity A problem where the risk of morbidity without treatment is high to extreme; there is a moderate to high risk of mortality without treatment OR high probability of severe, prolonged functional impairment. PAST HISTORY: A review of the patient's past experiences with illnesses, injuries, and treatments that includes significant information about: · prior major illnesses and injuries; · prior operations; · prior hospitalizations; · current medications; · allergies (e.g., drug, food); · age appropriate immunization status; · age appropriate feeding/dietary status. SOCIAL HISTORY: an age appropriate review of past and current activities that include significant information about: · marital status and/or living arrangements; · current employment; · occupational history; · use of drugs, alcohol, and tobacco; · level of education; · sexual history; · other relevant social factors. SYSTEM REVIEW (REVIEW OF SYSTEMS): An inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced. The following elements of a system review have been identified: · Constitutional symptoms (fever, weight loss, etc.) · Eyes · Ears, Nose, Mouth, Throat · Cardiovascular · Respiratory · Gastrointestinal · Genitourinary · Musculoskeletal · Integumentary (skin and/or breast) · Neurological · Psychiatric · Endocrine Version 2021-2 Page 9 of 64 Nurse Practitioner Procedure Codes · Hematologic/Lymphatic · Allergic/Immunologic The review of systems helps define the problem, clarify the differential diagnoses, identify needed testing, or serves as baseline data on other systems that might be affected by any possible management options. TIME: The inclusion of time in the definitions of levels of E/M services has been implicit in prior editions. The inclusion of time as an explicit factor beginning in 1992 is done to assist practitioners in selecting the most appropriate level of E/M services. It should be recognized that the specific times expressed in the visit code descriptors are averages, and therefore represent a range of times which may be higher or lower depending on actual clinical circumstances. Time is not a descriptive component for the emergency department levels of E/M services because emergency department services are typically provided on a variable intensity basis, often involving multiple encounters with several patients over an extended period of time. Therefore, it is often difficult for practitioners to provide accurate estimates of the time spent faceto-face with the patient. Intra-service times are defined as face-to-face time for office and other outpatient visits and as unit/floor time for hospital or other inpatient visits. This distinction is necessary because most of the work of typical office visits takes place during the face-to-face time with the patient, while most of the work of typical hospital visits takes place during the time spent on the patient's floor or unit. A. Face-to-face time (e.g., office and other outpatient visits, office consultations and all psychiatry procedures): For coding purposes, face-to-face time for these services is defined as only that time the practitioner spends face-to-face with the patient and/or family. This includes the time in which the practitioner performs such tasks as obtaining a history, performing an examination, and counseling the patient. Practitioners also spend time doing work before or after face-to-face time with the patient, performing such tasks reviewing records and tests, arranging for further services, and communicating further with other professionals and the patient through written reports and telephone contact. This non face-to-face time for office services also called pre- and post-encounter time is not included in the time component described in the E/M codes. However, the pre- and post-face-to-face work associated with an encounter was included in calculating the total work of typical services. Thus, the face-to-face time associated with the services described by any E/M code is a valid proxy for the total work done before, during, and after the visit. B. Unit/floor time (inpatient hospital care): For reporting purposes, intra-service time for these services is defined as unit/floor time, which includes the time that the practitioner is Version 2021-2 Page 10 of 64 Nurse Practitioner Procedure Codes present on the patient's hospital unit and at the bedside rendering services for that patient. This includes the time in which the practitioner establishes and/or reviews the patient's chart, examines the patient, writes notes and communicates with other professionals and the patient's family. In the hospital, pre- and post-time includes time spent off the patient's floor performing such tasks as reviewing pathology and radiology findings in another part of the hospital. This pre- and post-visit time is not included in the time component described in these codes. However, the pre- and post-work performed during the time spent off the floor or unit was included in calculating the total work of typical services. Thus, the unit/floor time associated with the services described by any code is a valid proxy for the total work done before, during and after the visit. 4A. LEVELS OF E/M SERVICES: Within each category or subcategory of E/M service, there are three to five levels of E/M services available for reporting purposes. Levels of E/M services are not interchangeable among the different categories or subcategories of service. For example, the first level of E/M services in the subcategory of office visit, new patient, does not have the same definition as the first level of E/M services in the subcategory of office visit, established patient. The levels of E/M services include examinations, evaluations, treatments, conferences with or concerning patients, preventive health supervision, and similar medical services such as the determination of the need and/or location for appropriate care. Medical screening includes the history, examination, and medical decision-making required to determine the need and/or location for appropriate care and treatment of the patient (e.g., office and other outpatient setting, emergency department, nursing facility, etc.). The levels of E/M services encompass the wide variations in skill, effort, time, responsibility and medical knowledge required for the prevention or diagnosis and treatment of illness or injury and the promotion of optimal health. The descriptors for the levels of E/M services recognize seven components, six of which are used in defining the levels of E/M services. These components are: history; examination, medical decision making, counseling; coordination of care; nature of presenting problem, and time. The first three of these components (history, examination and medical decision making) are considered the key components in selecting a level of E/M services. The next three components (counseling, coordination of care, and the nature of the presenting problem) are considered contributory factors in the majority of encounters. Although the first two of these contributory factors are important E/M services, it is not required that these services be provided at every patient encounter. The final component, time, has already been discussed in detail. The actual performance of diagnostic tests/studies for which specific codes are available is not included in the levels of E/M services. Practitioner performance of diagnostic tests/studies for Version 2021-2 Page 11 of 64 Nurse Practitioner Procedure Codes which specific codes are available should be reported separately, in addition to the appropriate E/M code. Version 2021-2 Page 12 of 64 Nurse Practitioner Procedure Codes 4B. INSTRUCTIONS FOR SELECTING A LEVEL OF E/M SERVICE: i. IDENTIFY THE CATEGORY AND SUBCATEGORY OF SERVICE: Select from the categories and subcategories of codes available for reporting E/M services. ii. REVIEW THE REPORTING INSTRUCTIONS FOR THE SELECTED CATEGORY OR SUBCATEGORY: Most of the categories and many of the subcategories of service have special guidelines or instructions unique to that category or subcategory. Where these are indicated, e.g., "Hospital Care", special instructions will be presented preceding the levels of E/M services. iii. REVIEW THE LEVEL OF E/M SERVICE DESCRIPTORS AND EXAMPLES IN THE SELECTED CATEGORY OR SUBCATEGORY: The descriptors for the levels of E/M services recognize seven components, six of which are used in defining the levels of E/M services. These components are: history, examination, medical decision making, counseling, coordination of care, nature of presenting problem, and time. The first three of these components (i.e., history, examination and medical decision making) should be considered the key components in selecting the level of E/M services. An exception to this rule is in the case of visits which consist predominantly of counseling or coordination of care (see vii.c.). The nature of the presenting problem and time are provided in some levels to assist the practitioner in determining the appropriate level of E/M service. iv. DETERMINE THE EXTENT OF HISTORY OBTAINED: The levels of E/M services recognize four types of history that are defined as follows: · Problem Focused chief complaint, brief history of present illness or problem. · Expanded Problem Focused chief complaint; brief history of present illness; problem pertinent system review. · Detailed chief complaint; extended history of present illness; problem pertinent system review extended to include review of a limited number of additional systems; pertinent past, family and/or social history directly related to the patient's problems. · Comprehensive chief complaint; extended history of present illness; review of systems which is directly related to the problem(s) identified in the history of the present illness plus a review of all additional body systems; complete past, family and social history. The comprehensive history obtained as part of the preventive medicine evaluation and management service is not problem-oriented and does not involve a chief complaint of present illness. It does, however, include a comprehensive system review and comprehensive or interval past, family and social history as well as a comprehensive assessment/history of pertinent risk factors. v. DETERMINE THE EXTENT OF EXAMINATION PERFORMED: The levels of E/M services recognize four types of examination that are defined as follows: · Problem Focused a limited examination of the affected body area or organ system. · Expanded Problem Focused a limited examination of the affected body area or organ system and other symptomatic or related organ system(s). · Detailed an extended examination of the affected body area(s) and other symptomatic or related organ system(s). Version 2021-2 Page 13 of 64 Nurse Practitioner Procedure Codes · Comprehensive a general multi-system examination or a complete examination of a single organ system. NOTE: The comprehensive examination performed as part of the preventive medicine evaluation and management service is multi-system, but its extent is based on age and risk factors identified. For the purposes of these definitions, the following organ systems are recognized: eyes, ears, nose, mouth and throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; skin, neurologic; psychiatric; hematologic/lymphatic/immunologic. vi. DETERMINE THE COMPLEXITY OF MEDICAL DECISION MAKING: Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by: · the number of possible diagnoses and/or the number of management options that must be considered; · the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed; and · the risk of significant complications, morbidity and/or mortality, as well as co-morbidities, associated with the patient's presenting problem(s), the diagnostic procedure(s) and/or the possible management options. Four types of medical decision making are recognized: straightforward; low complexity; moderate complexity, and, high complexity. To qualify for a given type of decision making, two of the three elements in the table following must be met or exceeded: Number of diagnoses or Amount and/or Risk of complications Type of decision management options complexity of data and/or morbidity or making to be reviewed mortality minimal minimal or none minimal straightforward limited limited low low complexity multiple moderate moderate moderate complexity extensive extensive high high complexity Co-morbidities/underlying disease, in and of themselves, are not considered in selecting a level of E/M services unless their presence significantly increases the complexity of the medical decision making. vii. SELECT THE APPROPRIATE LEVEL OF E/M SERVICES BASED ON THE FOLLOWING: a. For the following categories/subcategories, ALL OF THE KEY COMPONENTS (ie, history, examination, and medical decision making), must meet or exceed the stated requirements to qualify for a particular level of E/M service: office, new patient; hospital observation services; initial hospital care; office consultations; initial): inpatient consultations, emergency department services; initial nursing facility care; domiciliary care, new patient; and home, new patient. b. For the following categories/subcategories, TWO OF THE THREE KEY COMPONENTS (i.e., history, examination, and medical decision making) must meet or exceed the stated requirements to qualify for a particular level of E/M services: office, established patient; subsequent hospital care; subsequent nursing facility care; domiciliary care, established patient; and home, established patient. Version 2021-2 Page 14 of 64 Nurse Practitioner Procedure Codes c. In the case where counseling and or coordination of care dominates (more than 50%) the practitioner/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital), then time is considered the key or controlling factor to qualify for a particular level of E/M services. The extent of counseling and/or coordination of care must be documented in the medical record. NOTE: CLINICAL EXAMPLES: Clinical examples of the codes for E/M services are provided to assist practitioners in understanding the meaning of the descriptors and selecting the correct code. The same problem, when seen by physicians in different specialties, may involve different amounts of work. Therefore, the appropriate level of encounter should be reported using the descriptor rather than the examples. 5. FAMILY PLANNING CARE: In accordance with approval received by the State Director of the Budget, effective July 1, 1973 in the Medicaid Program, all family planning services are to be reported on claims using appropriate MMIS code numbers listed in this fee schedule in combination with modifier -FP. This reporting procedure will assure to New York State the higher level of federal reimbursement which is available when family planning services are provided to Medicaid patients (90% instead of 50% for other medical care). It will also provide the means to document conformity with mandated federal requirements on provision of family planning services. 6. EVALUATION AND MANAGEMENT SERVICES (OUTPATIENT OR INPATIENT): Evaluation and management fees do not apply to preoperative consultations or follow-up visits as designated in accordance with the surgical fees listed in the SURGERY section of the State Medical Fee Schedule. For additional information on the appropriate circumstances governing the billing of the hospital visit procedure codes see PRACTITIONER SERVICES PROVIDED IN HOSPITALS. EVALUATION AND MANAGEMENT CODES 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. OFFICE OR OTHER OUTPATIENT SERVICES The following codes are used to report evaluation and management services provided in the practitioner's office or in an outpatient or other ambulatory facility. A patient is considered an outpatient until inpatient admission to a health care facility occurs. When claiming for Evaluation and Management procedure codes report the place of service code that represents the location where the service was rendered in the claim form field for Place of Service. The maximum reimbursable amount for these codes is dependent on the Place of Service reported. Version 2021-2 Page 15 of 64 Nurse Practitioner Procedure Codes For Evaluation and Management services rendered in the practitioner's private office, report place of service "11". For services rendered in a Hospital Outpatient setting report place of service "22". To report services provided to a patient who is admitted to a hospital or nursing facility in the course of an encounter in the office or other ambulatory facility, see the notes for initial hospital inpatient care or comprehensive nursing facility assessments. NEW PATIENT 99202 Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and /or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter. 99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and /or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter. 99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and /or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter. 99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and /or examination and high level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on the date of the encounter. ESTABLISHED PATIENT The following codes are used to report the evaluation and management services provided to established patients who present for follow-up and/or periodic reevaluation of problems or for the evaluation and management of new problem(s) in established patients. 99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. 99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires medically appropriate history and/ or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter. 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/ or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter. Version 2021-2 Page 16 of 64 Nurse Practitioner Procedure Codes 99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/ or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter. 99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/ or examination and high level of medical decision making. When using time for code selection 40-54 minutes of total time is spent on the date of the encounter HOSPITAL OBSERVATION SERVICES The following codes are used to report evaluation and management services provided to patients designated/admitted as "observation status" in a hospital. It is not necessary that the patient be located in an observation are designated by the hospital. If such an area does exist in a hospital (as a separate unit in the hospital, in the emergency department, etc.), these codes are to be utilized if the patient is placed in such an area. Typical times have not yet been established for this category of services. OBSERVATION CARE DISCHARGE SERVICES Observation care discharge of a patient from "observation status" includes final examination of the patient, discussion of the hospital stay, instructions for continuing care, and preparation of discharge records. For observation or inpatient hospital care including the admission and discharge of the patient on the same date, see codes 99234-99236 as appropriate. 99217 Observation care discharge day management (This code is to be utilized by the practitioner to report all services provided to a patient on discharge from outpatient hospital "observation status" if the discharge is on other that the initial date of "observation status". To report services to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the codes for Observation or Inpatient Care Services (99234-99236). INITIAL OBSERVATION CARE- NEW OR ESTABLISHED PATIENT The following codes are used to report the encounter(s) by the supervising practitioner with the patient when designated as "observation status". This refers to the initiation of observation status, supervision of the care plan for observation and performance of periodic reassessments. To report services provided to a patient who is admitted to the hospital after receiving hospital observation care services on the same date, see the notes for initial hospital inpatient care. For a patient admitted to the hospital on a date subsequent to the date of observation status, the hospital admission would be reported with the appropriate initial hospital care codes (99221-99223). For a patient admitted and discharged from observation or inpatient status on the same date, the services should be reported with codes 99234-99236 as appropriate. Do not report observation discharge (99217) in conjunction with the hospital admission. Version 2021-2 Page 17 of 64 Nurse Practitioner Procedure Codes When "observation status" is initiated in the course of an encounter in another site of service (e.g., hospital emergency department, practitioner's office, nursing facility) all evaluation and management services provided by the supervising practitioner in conjunction with initiating "observation status" are considered part of the initial observation care when performed on the same date. The observation care level of service reported by the supervising practitioner should include the services related to initiating "observation status" provided in the other sites of service as well as in the observation setting. Evaluation and Management services on the same date provided in sites that are related to initiating "observation status" should NOT be reported separately. These codes may not be utilized for post-operative recovery if the procedure is considered a part of the surgical "package". These codes apply to all Evaluation and Management services that are provided on the same date of initiating "observation status". Version 2021-2 Page 18 of 64 Nurse Practitioner Procedure Codes 99218 Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components: · a detailed or comprehensive history; · a detailed or comprehensive examination; and · medical decision making that is straightforward or of low complexity. Usually the problem(s) requiring admission to outpatient hospital "observation status" are of low severity. Physicians typically spend 30 minutes at the bedside and on the patient's hospital floor or unit. 99219 Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: · a comprehensive history; · a comprehensive examination; and · medical decision making of moderate complexity. Usually the problem(s) requiring admission to outpatient hospital "observation status" are of moderate severity. Physicians typically spend 50 minutes at the bedside and on the patient's hospital floor or unit. 99220 Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: · a comprehensive history; · a comprehensive examination; and · medical decision making of high complexity. Usually the problem(s) requiring admission to outpatient hospital "observation status" are of high severity. Physicians typically spend 70 minutes at the bedside and on the patient's hospital floor or unit. SUBSEQUENT OBSERVATION CARE All levels of subsequent observation care include reviewing the medical record and reviewing the results of diagnostic studies and changes in the patient's status (ie, changes in history, physical condition, and response to management) since the last assessment by the physician. 99224 Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: · problem focused interval history; · problem focused examination; · medical decision making that is straightforward or of low complexity. Usually, the patient is stable, recovering, or improving. Physicians typically spend 15 minutes at the bedside and on the patient's hospital floor or unit. 99225 Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: · an expanded problem focused interval history; · an expanded problem focused examination; · medical decision making of moderate complexity. Version 2021-2 Page 19 of 64 Nurse Practitioner Procedure Codes Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient's hospital floor or unit. 99226 Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: · a detailed interval history; · a detailed examination; · medical decision making of high complexity. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient's hospital floor or unit. HOSPITAL INPATIENT SERVICES The following codes are used to report evaluation and management services provided to inpatients. INITIAL HOSPITAL CARE - NEW OR ESTABLISHED PATIENT The following codes are used to report the first hospital encounter with the patient by the admitting practitioner. For subsequent hospital care codes (99231-99233) as appropriate. 99221 Initial hospital care, per day, for the evaluation and management of a patient which requires these three key components: · a detailed or comprehensive history, · a detailed or comprehensive examination, and · medical decision making that is straightforward or of low complexity. Usually, the problem(s) requiring admission are of low severity. Practitioners typically spend 30 minutes at the bedside and on the patient's hospital floor or unit. 99222 Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: · a comprehensive history, · a comprehensive examination, and · medical decision making of moderate complexity. Usually, the problem(s) requiring admission are of moderate severity. Practitioners typically spend 50 minutes at the bedside and on the patient's hospital floor or unit. 99223 Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: · a comprehensive history, · a comprehensive examination, and · medical decision making of high complexity. Usually, the problem(s) requiring admission are of high severity. Practitioners typically spend 70 minutes at the bedside and on the patient's hospital floor or unit. SUBSEQUENT HOSPITAL CARE Version 2021-2 Page 20 of 64 Nurse Practitioner Procedure Codes All levels of subsequent hospital care include reviewing the medical record and reviewing the results of diagnostic studies and changes in the patient's status, (i.e., changes in history, physical condition and response to management) since the last assessment by the practitioner. 99231 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: · a problem focused interval history, · a problem focused examination, and/or · medical decision making that is straightforward or of low complexity. Usually, the patient is stable, recovering or improving. Practitioners typically spend 15 minutes at the bedside and on the patient's hospital floor or unit. 99232 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: · an expanded problem focused interval history, · an expanded problem focused examination, and/or · medical decision making of moderate complexity. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Practitioners typically spend 25 minutes at the bedside and on the patient's hospital floor or unit. 99233 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: · a detailed interval history, · a detailed examination, and/or · medical decision making of high complexity. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Practitioners typically spend 35 minutes at the bedside and on the patient's hospital floor or unit OBSERVATION OR INPATIENT CARE SERVICES (INCLUDING ADMISSION AND DISCHARGE SERVICES) The following codes are used to report observation or inpatient hospital care services provided to patients admitted and discharged on the same date of service. When a patient is admitted to the hospital from observation status on the same date, the practitioner should report only the initial hospital care code. The initial hospital care code reported by the admitting practitioner should include the services related to the observation status services he/she provided on the same date of inpatient admission. When "observation status" is initiated in the course of an encounter in another site of service (e.g., hospital emergency department, practitioner's office, nursing facility) all evaluation and management services provided by the supervising practitioner in conjunction with initiating "observation status" are considered part of the initial observation care when performed on the same date. The observation Version 2021-2 Page 21 of 64 Nurse Practitioner Procedure Codes care level of service should include the services related to initiating "observation status" provided in the other sites of service as well as in the observation setting when provided by the same practitioner. 99234 Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date which requires these three key components: · a detailed or comprehensive history; · a detailed or comprehensive examination; and · medical decision making that is straightforward or of low complexity. Usually the presenting problem(s) requiring admission are of low severity. 99235 Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date which requires these three key components: · a comprehensive history; · a comprehensive examination; and · medical decision making of moderate complexity. Usually the presenting problem(s) requiring admission are of moderate severity. 99236 Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date which requires these three key components: · a comprehensive history; · a comprehensive examination; and · medical decision making of high complexity. Usually the presenting problem(s) requiring admission are of high severity. HOSPITAL DISCHARGE SERVICES The hospital discharge day management codes are to be used to report the total duration of time spent by a practitioner for final hospital discharge of a patient. The codes include, as appropriate, final examination of the patient, discussion of the hospital stay, even if the time spent by the practitioner on that date is not continuous, instructions for continuing care to all relevant caregivers, and preparation of discharge records, prescriptions and referral forms. For patients admitted and discharged from observation or inpatient status on the same date, the service should be reported with codes 9923499236 as appropriate. 99238 99239 Hospital discharge day management; 30 minutes or less more than 30 minutes (These codes are to be utilized by the practitioner to report all services provided to a patient on the date of discharge, if other than the initial date of inpatient status. To report services to a patient who is admitted as an inpatient, and discharge on the same date, see codes 99234-99236 for observation or inpatient hospital care including the admission and discharge of the patient on the same date. To report concurrent care services provided by a practitioner(s) other than the attending practitioner, use subsequent hospital care codes (99231-99233) on the day of discharge.) Version 2021-2 Page 22 of 64 Nurse Practitioner Procedure Codes EMERGENCY DEPARTMENT SERVICES - NEW OR ESTABLISHED PATIENT The following codes are used to report evaluation and management services provided in the emergency department. No distinction is made between new and established patients in the emergency department. An emergency department is defined as an organized hospital based facility for the provision of unscheduled episodic services to patients who present for immediate medical attention. The facility must be available 24 hours a day. 99281 Emergency department visit for the evaluation and management of a patient, which requires these three key components: · a problem focused history, · a problem focused examination, and · straightforward medical decision making. Usually, the presenting problem(s) are self-limited or minor. 99282 Emergency department visit for the evaluation and management of a patient, which requires these three key components: · an expanded problem focused history, · an expanded problem focused examination, and · medical decision making of low complexity. Usually, the presenting problem(s) are of low to moderate severity. 99283 Emergency department visit for the evaluation and management of a patient, which requires these three key components: · an expanded problem focused history, · an expanded problem focused examination, and · medical decision making of moderate complexity. Usually, the presenting problem(s) are of moderate severity. 99284 Emergency department visit for the evaluation and management of a patient, which requires these three key components: · a detailed history; · a detailed examination; and · medical decision making of moderate complexity. Usually, the presenting problem(s) are of high severity and require urgent evaluation by the physician but do not pose an immediate significant threat to life or physiologic function. 99285 Emergency department visit for the evaluation and management of a patient, which requires these three key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: · a comprehensive history, · a comprehensive examination, and · medical decision making of high complexity. Version 2021-2 Page 23 of 64 Nurse Practitioner Procedure Codes Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. NURSING FACILITY SERVICES The following codes are used to report evaluation and management services to patients in Nursing Facilities (formerly called Skilled Nursing Facilities (SNFs), Intermediate Care Facilities (ICFs) or Long Term Care Facilities (LTCFs)). INITIAL NURSING FACILITY CARE NEW OR ESTABLISHED PATIENT More than one comprehensive assessment may be necessary during an inpatient confinement. 99304 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: · a detailed or comprehensive history; · a detailed or comprehensive examination; and · medical decision making that is straightforward or of low complexity. Usually, the problem(s) requiring admission are of low severity. Physicians typically spend 25 minutes at the bedside and on the patient's facility floor or unit. 99305 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: · a comprehensive history; · a comprehensive examination; and · medical decision making of moderate complexity. Usually, the problem(s) requiring admission are of moderate severity. Physicians typically spend 35 minutes at the bedside and on the patient's facility floor or unit. 99306 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: · a comprehensive history; · a comprehensive examination; and · medical decision making of high complexity. Usually, the problem(s) requiring admission are of high severity. Physicians typically spend 45 minutes at the bedside and on the patient's facility floor or unit. SUBSEQUENT NURSING FACILITY CARE The following codes are used to report the services provided to residents of nursing facilities who do not require a comprehensive assessment, and/or who have not had a major, permanent change of status. All levels of subsequent nursing facility care include reviewing the medical record and reviewing the results of diagnostic studies and changes in the patient's status (ie, changes in history, physical condition, and response to management) since the last assessment by the physician. Version 2021-2 Page 24 of 64 Nurse Practitioner Procedure Codes 99307 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: · a problem focused interval history; · a problem focused examination; · straightforward medical decision making. Usually, the patient is stable, recovering, or improving. Physicians typically spend 10 minutes at the bedside and on the patient's facility floor or unit. 99308 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: · an expanded problem focused interval history; · an expanded problem focused examination; · medical decision making of low complexity. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 15 minutes at the bedside and on the patient's facility floor or unit. 99309 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: · a detailed interval history; · a detailed examination; · medical decision making of moderate complexity. Usually, the patient has developed a significant complication or a significant new problem. Physicians typically spend 25 minutes at the bedside and on the patient's facility floor or unit. 99310 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: · a comprehensive interval history; · a comprehensive examination; · medical decision making of high complexity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Physicians typically spend 35 minutes at the bedside and on the patient's facility floor or unit. NURSING FACILITY DISCHARGE SERVICES The nursing facility discharge day management codes are to be used to report the total duration of time spent by a practitioner for the final nursing facility discharge of patient. The codes include, as appropriate, final examination of the patient, discussion of the nursing facility stay, even if the time spent by the practitioner on that date is not continuous. Instructions are given for continuing care to all relevant caregivers, and preparation of discharge records, prescriptions and referral forms. 99315 99316 Nursing facility discharge day management; 30 minutes or less more than 30 minutes Version 2021-2 Page 25 of 64 Nurse Practitioner Procedure Codes DOMICILIARY, REST HOME (e.g., BOARDING HOME), OR CUSTODIAL CARE SERVICES The following codes are used to report evaluation and management services in a facility which provides room, board and other personal assistance services, generally on a long-term basis. The facility's services do not include a medical component. NEW PATIENT 99324 Domiciliary or rest home 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 · medical decision making that is straightforward. Usually, the presenting problem(s) are of low severity. Practitioners typically spend 20 minutes with the patient and/or family or caregiver. 99325 Domiciliary or rest home 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 · medical decision making of low complexity. Usually, the presenting problem(s) are of moderate severity. Practitioners typically spend 30 minutes with the patient and/or family or caregiver. 99326 Domiciliary or rest home 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 moderate complexity. Usually, the presenting problem(s) are of moderate to high complexity. Practitioners typically spend 45 minutes with the patient and/or family or caregiver. 99327 Domiciliary or rest home 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. Usually, the presenting problem(s) are of moderate to high severity. Practitioners typically spend 60 minutes with the patient and/or family or caregiver. Version 2021-2 Page 26 of 64 Nurse Practitioner Procedure Codes 99328 Domiciliary or rest home 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. Usually, the patient is unstable or has developed a significant new problem requiring immediate physician attention. Practitioners typically spend 75 minutes with the patient and/or family or caregiver. ESTABLISHED PATIENT 99334 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least two of these three key components: · a problem focused interval history, · a problem focused examination, and/or · medical decision making that is straightforward. Usually, the presenting problem(s) are self-limited or minor. Practitioners typically spend 15 minutes with the patient and/or family or caregiver. 99335 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least two of these three key components: · an expanded problem focused interval history, · an expanded problem focused examination, and/or · medical decision making of low complexity. Usually, the presenting problem(s) are of low to moderate severity. Practitioners typically spend 25 minutes with the patient and/or family or caregiver. 99336 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least two of these three key components: · a detailed interval history, · a detailed examination, and/or · medical decision making of moderate complexity. Usually, the presenting problem(s) are of moderate to high severity. Practitioners typically spend 40 minutes with the patient and/or family or caregiver. 99337 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least two of these three key components: · a comprehensive interval history, · a comprehensive examination, and · medical decision making of moderate to high complexity. Usually, the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Practitioners typically spend 60 minutes with the patient and/or family or caregiver. Version 2021-2 Page 27 of 64 Nurse Practitioner Procedure Codes HOME SERVICES The following codes are used to report evaluation and management services provided in a private residence. NEW PATIENT 99341 Home 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 · medical decision making that is straightforward. Usually the presenting problem(s) are of low severity. Practitioners typically spend 20 minute face-to-face with the patient and/or family. 99342 Home 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 · medical decision making of low complexity. Usually, the presenting problem(s) are of moderate severity. Practitioners typically spend 30 minutes face-to-face with the patient and/or family. 99343 Home 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 moderate complexity. Usually, the presenting problem(s) are of moderate to high severity. Practitioners typically spend 45 minutes face-to-face with patient and/or family. 99344 Home 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. Usually the presenting problem(s) are of high severity. Practitioners typically spend 60 minutes face-to-face with the patient and/or family. 99345 Home 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. Usually the patient is unstable or has developed a significant new problem requiring immediate Practitioner attention. Practitioners typically spend 75 minutes face-to-face with the patient and/or family. Version 2021-2 Page 28 of 64 ESTABLISHED PATIENT Nurse Practitioner Procedure Codes 99347 Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: · a problem focused interval history; · a problem focused examination and · straightforward medical decision making. Usually the presenting problem(s) are self-limited or minor. Practitioners typically spend 15 minutes face-to-face with the patient and/or family. 99348 Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: · an expanded problem focused interval history; · an expanded problem focused examination; · medical decision making of low complexity. Usually the presenting problem(s) are of low to moderate severity. Practitioners typically spend 25 minutes face-to-face with the patient and/or family. 99349 Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: · a detailed interval history; · a detailed examination; · medical decision making of moderate complexity. Usually the presenting problem(s) are of moderate to high severity. Practitioners typically spend 40 minutes face-to-face with the patient and/or family. 99350 Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: · a comprehensive interval history; · a comprehensive examination; · medical decision making of moderate to high complexity. Usually the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate practitioner attention. Practitioners typically spend 60 minutes face-to-face with the patient and/or family. PROLONGED SERVICES WITH OR WITHOUT DIRECT PATIENT CONTACT ON THE DATE OF AN OFFICE VISIT OR OTHER OUTPATIENT SERVICE 99417 Prolonged office or other outpatient evaluation and management service(s) beyond the minimum required time of the primary procedure which has been selected using total time, requiring total time with or without direct patient contact beyond the usual service on the date of primary service, each 15 minutes of total time ( List separately in addition to codes 99205,99215 for office or other outpatient Evaluation and Management services) Version 2021-2 Page 29 of 64 Nurse Practitioner Procedure Codes PREVENTIVE MEDICINE SERVICES The following codes are used to report well visit services. NEW PATIENT 99381 99382 99383 99384 99385 99386 99387 Initial comprehensive preventive 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 laboratory/diagnostic procedures, new patient; infant (age younger than 1 year) early childhood (age 1 through 4 years) late childhood (age 5 through 11 years) adolescent (age 12 through 17 years) 18-39 years 40-64 years 65 years and older ESTABLISHED PATIENT 99391 99392 99393 99394 99395 99396 99397 Periodic comprehensive preventive 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 laboratory/diagnostic procedures, established patient; infant (age younger than 1 year) early childhood (age 1 through 4 years) late childhood (age 5 through 11 years) adolescent (age 12 through 17 years) 18 - 39 years 40 - 64 years 65 years and older COUNSELING RISK FACTOR REDUCTION AND BEHAVIOR CHANGE INTERVENTION BEHAVIOR CHANGE INTERVENTIONS, INDIVIDUAL 99406 Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes 99407 intensive, greater than 10 minutes Version 2021-2 Page 30 of 64 Nurse Practitioner Procedure Codes NEWBORN CARE SERVICES The following codes are used to report the services provided to newborns (birth through the first 28 days) in several different settings. Use of the newborn codes is limited to the initial care of the newborn in the first days after birth prior to home discharge. 99460 99462 99463 Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant Subsequent hospital care, per day, for evaluation and management of normal newborn Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant admitted and discharged on the same date LABORATORY SERVICES PERFORMED IN THE OFFICE Certain laboratory procedures specified below are eligible for direct nurse practitioner reimbursement when performed in the office of the nurse practitioner in the course of treatment of her own patients. The nurse practitioner must be registered with the federal Health Care Finance Administration (HCFA) to perform laboratory procedures as required by the federal Clinical Laboratory Improvement Amendments of 1988 (CLIA '88). Procedures other than those specified must be performed by a laboratory, holding a valid clinical laboratory permit in the commensurate laboratory, specialty issued by the New York State Department of Health or, where appropriate, the New York City Department of Health. For detection of pregnancy, use code 81025. Procedure code 85025, complete blood count (CBC), may not be billed with its component codes 85007, 85013, 85018, 85041 or 85048. 81000 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy 81001 automated, with microscopy 81002 non-automated, without microscopy 81003 automated, without microscopy 81015 Urinalysis; microscopic only 81025 Urine pregnancy test, by visual color comparison methods 83655 Lead 85007 Blood count; blood smear, microscopic examination with manual differential WBC count 85013 spun microhematocrit 85018 hemoglobin (Hgb) 85025 complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count 85041 red blood cell (RBC) automated 85048 leukocyte (WBC), automated 85651 Sedimentation rate, erythrocyte; non-automated Version 2021-2 Page 31 of 64 Nurse Practitioner Procedure Codes 85652 automated 86701 Antibody; HIV-1 86703 HIV-1 and HIV-2, single result 87081 Culture, presumptive, pathogenic organisms, screening only; 87651 Streptococcus, group A, amplified probe technique 87806 HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies 87880 Streptococcus, group A 87428 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]) and influenza virus types A and B 87636 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) and influenza virus types A and B, multiplex amplified probe technique 87811 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) NOTE: Medicare reimburses for these services at 100 percent. No Medicare co-insurance payments may be billed for the above listed procedure codes. DRUGS AND DRUG ADMINISTRATION IMMUNIZATIONS If a significantly separately identifiable Evaluation and Management services (eg, office service, preventative medicine services) is performed, the appropriate E/M code should be reported in addition to the vaccine and toxoid codes. Immunizations are usually given in conjunction with a medical service. When an immunization is the only service performed, a minimal service may be listed in addition to the injection. Immunization procedures include reimbursement for the supply of materials and administration. Reimbursement for drugs (including vaccines and immune globulins) furnished by practitioners to their patients is based on the acquisition cost to the practitioner of the drug dose administered to the patient. For all drugs furnished in this fashion it is expected that the practitioner will maintain auditable records of the actual itemized invoice cost of the drug, including the numbers of doses of the drug represented on the invoice. New York State Medicaid does not intend to pay more than the acquisition cost of the drug dosage, as established by invoice, to the practitioner. Regardless of whether an invoice must be submitted to Medicaid for payment, the practitioner is expected to limit his or her Medicaid claim amount to the actual invoice cost of the drug dosage administered. IMMUNE GLOBULINS Immune globulin products listed here include broad-spectrum and anti-infective immune globulins, antitoxins, and various isoantibodies. Version 2021-2 Page 32 of 64 Nurse Practitioner Procedure Codes 90291 90371 90375 90376 90377 90378 90384 90385 90386 90389 90393 90396 90399 Cytomegalovirus immune globulin (CMV-lgIV), human, for intravenous use Hepatitis B immune globulin (HBlg), human, for intramuscular use Rabies immune globulin (Rlg), human, for intramuscular and/or subcutaneous Rabies immune globulin, heat-treated (RIg-HT), human, for intramuscular and/or subcutaneous use Rabies immune globin, heat-and solvent/detergent-treated (RIg-HT S/D), human, for intramuscular and /or subcutaneous use Respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular use, 50 mg, each Rho(D) immune globulin (Rhlg), human, full-dose, for intramuscular use Rho(D) immune globulin (Rhlg), human, mini-dose, for intramuscular use Rho(D) immune globulin (RhIgIV), human, for intravenous use Tetanus immune globulin (Tlg), human, for intramuscular use Vaccinia immune globulin, human, for intramuscular use Varicella-zoster immune globulin, human, for intramuscular use Unlisted immune globulin IMMUNIZATION ADMINISTRATION FOR VACCINES/TOXOIDS 90460 90471 90472 90473 90474 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered) Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (list separately in addition to code for primary procedure)) Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid) Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (list separately in addition to code for primary procedure) VACCINES/TOXOIDS For dates of service on or after 7/1/03 when immunization materials are supplied by the Vaccines for Children Program (VFC), bill using the procedure code that represents the immunization(s) administered and append modifier SL State Supplied Vaccine to receive the VFC administration fee. See Modifier Section for further information. For administration of vaccines supplied by VFC, including influenza and pneumococcal administration, providers will be required to bill vaccine administration code 90460. Providers must continue to bill the specific vaccine code with the "SL" modifier on the claim (payment for "SL" will be $0.00). If an administration code is billed without a vaccine code with "SL", the claim will be denied. For reimbursement purposes, the administration of the components of a combination vaccine will continue to be considered as one vaccine administration. More than one vaccine administration is reimbursable under 90460 on a single date of service. Version 2021-2 Page 33 of 64 Nurse Practitioner Procedure Codes NOTE: The maximum fees for immunization injection codes are adjusted periodically by the State to reflect the current acquisition cost of the antigen. For immunizations not supplied by the VFC Program insert acquisition cost in amount charged field on claim form. For codes listed BR/Report required, also attach itemized invoice to claim form. To meet the reporting requirements of immunization registries, vaccine distribution programs, and reporting systems (eg, Vaccine Adverse Event Reporting System) the exact vaccine product administered needs to be reported with modifier -SL. Multiple codes for a particular vaccine are provided in CPT when the schedule (number of doses or timing) differs for two or more products of the same vaccine type (eg, hepatitis A, Hib) or the vaccine product is available in more than one chemical formulation, dosage, or route of administration. Version 2021-2 Page 34 of 64 Nurse Practitioner Procedure Codes Separate codes are available for combination vaccines (eg, DTP-Hib, DtaP-Hib, HepB-Hib). It is inappropriate to code each component of a combination vaccine separately. If a specific vaccine code is not available, the Unlisted procedure code should be reported, until a new code becomes available. 90585 90586 90620 90621 90630 90632 90633 90636 90647 90648 90649 90650 90651 90653 90654 90655 90656 90657 90658 90660 90661 90662 90670 90672 90673 90674 90675 Bacillus Calmette-Guerin vaccine (BCG) for tuberculosis, live, for percutaneous use Bacillus Calmette-Guerin vaccine (BCG) for bladder cancer, live, for intravesical use Meningococcal recombinant protein and outer membrane vesicle vaccine, Serogroup B, (MenB-4C),2 dose schedule, for intramuscular use Meningococcal recombinant lipoprotein vaccine, Serogroup B,(MenB-FHpb), 2 or 3 dose schedule, for intramuscular use Influenza vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use Hepatitis A vaccine (HepA), adult dosage, for intramuscular use Hepatitis A vaccine (Hep A),pediatric/adolescent dosage-2 dose schedule, for intramuscular use Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for intramuscular use Haemophilus influenza type b vaccine (Hib), PRP-OMP conjugate, 3 dose schedule, for intramuscular use Haemophilus influenza type b vaccine (Hib), PRP-T conjugate, 4 dose schedule, for intramuscular use Human Papillomavirus vaccine, types 6, 11, 16, 18 quadrivalent (4vHPV), 3 dose schedule, for intramuscular use Human Papillomavirus vaccine, types 16, 18, bivalent (2vHPV), 3 dose schedule, for intramuscular use Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (9vHPV), 2 or 3 dose schedule, for intramuscular use Influenza vaccine, inactivated (IIV), subunit, adjuvanted, for intramuscular use Influenza virus vaccine, trivalent (IIV3), split virus, preservative-free, for intradermal use Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.25 mL dosage, for intramuscular use Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.5mL dosage, for intramuscular use Influenza virus vaccine, trivalent (IIV3), split virus, 0.25 mL dosage, for intramuscular use Influenza virus vaccine, trivalent (IIV3), split virus, 0.5 mL dosage for intramuscular use Influenza virus vaccine, trivalent, live (LAIV3), for intranasal use Influenza virus vaccine trivalent(ccIIV3), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use Influenza virus vaccine (IIV), split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use Pneumococcal conjugate vaccine, 13 valent (PCV13), for intramuscular use Influenza virus vaccine, quadrivalent, live (LAIV4), for intranasal use Influenza virus vaccine, trivalent (RIV3), derived from recombinant DNA (RIV3), hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use Influenza virus vaccine; quadrivalent (ccIIV4), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use Rabies vaccine, for intramuscular use Version 2021-2 Page 35 of 64 Nurse Practitioner Procedure Codes 90676 Rabies vaccine, for intradermal use 90680 Rotavirus vaccine, pentavalent (RV5), 3 dose schedule, live, for oral use 90681 Rotavirus vaccine, human, attenuated (RV1), 2 dose schedule, live, for oral use 90682 Influenza virus vaccine, quadrivalent (RIV4),derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use 90685 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.25 mL dosage, for intramuscular use 90686 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 mL dosage, for intramuscular use 90688 Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.5 mL dosage, for intramuscular use 90690 Typhoid vaccine, live, oral 90691 Typhoid vaccine, Vi capsular polysaccharide (ViCPs), for intramuscular use 90694 Influenza virus vaccine, quadrivalent, (allV4), inactivated, adjuvanted, preservative free, 0.5 mL dosage, for intramuscular use. 90696 Diphtheria, tetanus toxoids, acellular pertussis vaccine and inactivated poliovirus vaccine, (DTaP-IPV), when administered to children 4 through 6 years of age, for intramuscular use 90698 Diphtheria, tetanus toxoids, acellular pertussis vaccine, Haemophilus influenzae type B, and inactivated poliovirus vaccine, (DTaP IPV/Hib), for intramuscular use 90700 Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when administered to individuals younger than 7 years, for intramuscular use 90702 Diphtheria and tetanus toxoids adsorbed (DT) when administered to individuals younger than 7 years, for intramuscular use 90707 Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use 90710 Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use 90713 Poliovirus vaccine, inactivated, (IPV), for subcutaneous or intramuscular use 90714 Tetanus and diphtheria toxoids adsorbed (Td), preservative free, when administered to individuals 7 years or older, for intramuscular use 90715 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular use 90716 Varicella virus vaccine (VAR), live, for subcutaneous use 90717 Yellow fever vaccine, live, for subcutaneous use 90723 Diphtheria, tetanus toxoids, acellular pertussis vaccine, hepatitis B, and inactivated poliovirus vaccine, (DTaP-HepB-IPV), for intramuscular use 90732 Pneumococcal polysaccharide vaccine, 23-valent,(PPSV23),adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use 90733 Meningococcal polysaccharide vaccine, serogroups A,C,Y,W-135,quadrivalent (MPSV4),for subcutaneous use 90734 Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 , quadrivalent (MCV4 or MenACWY), for intramuscular use 90736 Zoster (shingles) vaccine,(HZV),live, for subcutaneous injection 90738 Japanese encephalitis virus vaccine, inactivated, for intramuscular use 90739 Hepatitis B vaccine (HepB), adult dosage, 2 dose schedule, for intramuscular use 90740 Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage, 3 dose schedule, for intramuscular use Version 2021-2 Page 36 of 64 Nurse Practitioner Procedure Codes 90743 90744 90746 90747 90748 90749 90750 90756 Hepatitis B vaccine (HepB), adolescent, 2 dose schedule, for intramuscular use Hepatitis B vaccine (HepB), pediatric/adolescent dosage, 3 dose schedule, for intramuscular use Hepatitis B vaccine (HepB), adult dosage, 3 dose schedule, for intramuscular use Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use Hepatitis B and Haemophilus influenza type b (Hib-HepB), for intramuscular use Unlisted vaccine/toxoid Zoster (shingles) vaccine (HZV), recombinant, subunit, adjuvanted, for intramuscular use Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, antibiotic free, 0.5 ml dosage, for intramuscular use DRUGS ADMINISTERED OTHER THAN ORAL METHOD The following list of drugs can be injected either subcutaneous, intramuscular or intravenously. A listing of chemotherapy drugs can be found in the Chemotherapy Section. New York State Medicaid's policy for coverage of drugs administered by subcutaneous, intramuscular or intravenous methods in the physician's office is as follows: These drugs are covered for FDA approved indications and those recognized off-label indications listed in the drug compendia (the American Hospital Formulary Service Drug Information, United States Pharmacopeia-Drug Information, the DrugDex information system or Facts and Comparisons). In the absence of such a recognized indication, an approved Institutional Review Board (IRB) protocol would be required with documentation maintained in the patient's clinical file. Drugs are not covered for investigational or experimental use. Reimbursement for drugs (including vaccines and immune globulins) furnished by practitioners to their patients is based on the acquisition cost to the practitioner of the drug dose administered to the patient. For all drugs furnished in this fashion it is expected that the practitioner will maintain auditable records of the actual itemized invoice cost of the drug, including the numbers of doses of the drug represented on the invoice. New York State Medicaid does not intend to pay more than the acquisition cost of the drug dosage, as established by invoice, to the practitioner. Regardless of whether an invoice must be submitted to Medicaid for payment, the practitioner is expected to limit his or her Medicaid claim amount to the actual invoice cost of the drug dosage administered. NOTE: The maximum fees for these drugs are adjusted periodically by the State to reflect the estimated acquisition cost. Insert acquisition cost per dose in amount charged field on claim form. For codes listed as BR in the Fee Schedule, also attach an itemized invoice to claim form. THERAPEUTIC INJECTIONS (Maximum fee includes cost of materials) J0121 J0129 J0135 Omadacycline, 1 mg Abatacept, 10 mg (Administered under direct physician supervision, not for self-administration) Adalimumab, 20 mg Version 2021-2 Page 37 of 64 Nurse Practitioner Procedure Codes J0153 J0171 J0180 J0185 Adenosine, 1 mg (Not to be used to report any adenosine phosphate compounds, instead use unlisted code) Adrenalin, epinephrine, 0.1 mg Agalsidase beta, 1 mg Aprepitant, 1 mg J0202 Alemtuzumab, 1 mg J0205 Alglucerase, per 10 units J0207 Amifostine, 500 mg J0210 Methyldopate HCl, up to 250 mg J0215 Alefacept, 0.5 mg J0222 Patisiran, 0.1 mg J0223 Givosiran, 0.5 mg J0256 Alpha 1proteinase inhibitor (human), not otherwise specified, 10 mg J0270 Alprostadil, per 1.25 mcg (Administered under direct physician supervision, not for self-administration) J0275 Alprostadil urethral suppository (Administered under direct physician supervision, not for self-administration) J0280 Aminophylline, up to 250 mg J0290 Ampicillin sodium, up to 500 mg J0291 Plazomicin, 5 mg J0295 Ampicillin sodium/sulbactam sodium, per 1.5 gm J0300 Amobarbital, up to 125 mg J0360 Hydralazine HCl, up to 20 mg J0380 Metaraminol bitartrate, per 10 mg J0390 Chloroquine HCl, up to 250 mg J0456 Azithromycin, 500 mg J0461 Atropine sulfate, 0.01 mg J0470 Dimercaprol, per 100 mg J0475 Baclofen, 10 mg J0500 Dicyclomine HCl, up to 20 mg J0515 Benztropine mesylate, per 1 mg J0517 Benralizumab, 1 mg J0520 Bethanechol chloride, myotonachol or urecholine, up to 5 mg J0558 Penicillin G benzathine and penicillin G procaine, 100,000 units J0561 Penicillin G benzathine, 100,000 units J0565 Bezlotoxumab, 10 mg J0584 Burosumab-twza, 1mg J0585 OnabotulinumtoxinaA, 1 unit J0586 AbobotulinumtoxinaA, 5 units J0587 RimabotulinumtoxinB, 100 units J0593 Lanadelumab-flys\o, 1 mg (Administered under direct physician supervision, not for self-administration) J0599 C1 esterase inhibitor (human), (haegarda), 10 units J0600 Edetate calcium disodium, up to 1000 mg Version 2021-2 Page 38 of 64 Nurse Practitioner Procedure Codes J0610 Calcium gluconate, per 10 ml J0620 Calcium glycerophosphate and calcium lactate, per 10 ml J0630 Calcitonin salmon, up to 400 units J0636 Calcitriol, 0.1 mcg J0640 Leucovorin calcium, per 50 mg J0641 Levoleucovorin, not otherwise specified, 0.5 mg J0642 Levoleucovorin (khapzory), 0.5 mg J0690 Cefezolin sodium, up to 500 mg J0694 Cefoxitin sodium, 1 gm J0696 Ceftriaxone sodium, per 250 mg J0697 Sterile cefuroxime sodium, per 750 mg J0698 Cefotaxime sodium, per gm J0702 Betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg J0710 Cephapirin sodium, up to 1 gm J0713 Ceftazidime, per 500 mg J0715 Ceftizoxime sodium, per 500 mg J0720 Chloramphenicol sodium succinate, up to 1 gm J0725 Chorionic gonadotropin, per 1,000 USP units J0740 Cidofovir, 375 mg J0744 Ciprofloxacin for intravenous infusion, 200 mg J0745 Codeine phosphate, per 30 mg J0770 Colistimethate sodium, up to 150 mg J0780 Prochlorperazine, up to 10 mg J0791 Crizanlizumab-tmca, 5mg J0834 Cosyntropin 0.25 mg J0875 Dalbavancin, 5 mg J0881 Darbepoetin alfa, 1 mcg (Non-ESRD use) J0885 Epoetin alfa, (Non-ESRD use), 1000 units J0888 Epoetin beta, 1 mcg (Non-ESRD-use) J0895 Deferoxamine mesylate, 500 mg J0896 Luspatercept-aamt, 0.25 mg J0945 Brompheniramine maleate, per 10 mg J1000 Depo-estradiol cypionate, up to 5 mg J1020 Methylprednisolone acetate, 20 mg J1030 Methylprednisolone acetate, 40 mg J1040 Methylprednisolone acetate, 80 mg J1050 Injection, medroxyprogesterone acetate, 1 mg J1071 Testosterone cypionate, 1 mg J1094 Dexamethasone acetate, 1 mg J1100 Dexamethasone sodium phosphate, 1 mg J1110 Dihydroergotamine mesylate, per 1 mg J1120 Acetazolamide sodium, up to 500 mg J1160 Digoxin, up to 0.5 mg J1165 Phenytoin sodium, per 50 mg J1170 Hydromorphone, up to 4 mg Version 2021-2 Page 39 of 64 Nurse Practitioner Procedure Codes J1180 Dyphylline, up to 500 mg J1190 Dexrazoxane HCl, per 250 mg J1200 Diphenhydramine HCl, up to 50 mg J1205 Chlorothiazide sodium, per 500 mg J1212 DMSO, dimethyl sulfoxide, 50%, 50 ml J1230 Methadone HCl, up to 10 mg J1240 Dimenhydrinate, up to 50 mg J1260 Dolasetron mesylate, 10 mg J1300 Eculizumab, 10 mg J1301 Edaravone, 1 mg J1320 Amitriptyline HCl, up to 20 mg J1322 Elosulfase alfa, 1 mg J1330 Ergonovine maleate, up to 0.2 mg J1364 Erythromycin lactobionate, per 500 mg J1380 Estradiol valerate, up to 10 mg J1410 Estrogen conjugated, per 25 mg J1435 Estrone, per 1 mg J1436 Etidronate disodium, per 300 mg J1437 Ferric derisomaltose, 10 mg J1438 Etanercept, 25 mg (Administered under direct physician supervision, not self-administered) J1439 Ferric Carboxymaltose, 1 mg J1442 Filgrastim (G CSF),excludes biosimilars, 1 microgram J1447 Tbo-Filgrastim, 1 microgram J1450 Fluconazole, 200 mg J1452 Fomivirsen sodium, intraocular, 1.65 mg J1453 Fosaprepitant, 1 mg J1454 Fosnetupitant 235 mg and palonestron 0.25 mg J1455 Foscarnet sodium, per 1000 mg J1458 Galsulfase, 1 mg J1459 Immune globulin (Privigen), intravenous, non lyophilized (e.g. liquid), 500 mg J1460 Gamma globulin, intramuscular, 1 cc J1554 Immune globulin (Asceniv), 500 mg J1555 Immune Globulin (Cuvitru), 100 mg J1556 Immune Globulin (Bivigam), 500 mg J1560 Gamma globulin, intramuscular, over 10 cc J1561 Immune globulin, (Gamunex-C/Gammaked), non-lyophilized (e.g. liquid), 500 mg J1562 Immune globulin (Vivaglobin), 100 mg J1566 Immune globulin, intravenous, lyophilized (e.g. powder), not otherwise specified, 500 mg J1568 Immune globulin, (Octagam), intravenous, non-lyophilized (e.g. liquid), 500 mg J1569 Immune globulin, (Gammagard Liquid), non-lyophilized, (e.g. liquid), 500 mg J1570 Ganciclovir sodium, 500 mg J1572 Immune globulin, (flebogamma/flebogamma DIF), intravenous, non-lyophilized (e.g. liquid), 500 mg J1573 Hepatitis B immune globulin (HepaGam B), intravenous, 0.5 ml Version 2021-2 Page 40 of 64 Nurse Practitioner Procedure Codes J1575 Immune Globulin/Hyaluronidase (HYQVIA), 100 mg J1580 Garamycin, gentamicin, up to 80 mg J1595 Glatiramer acetate, 20 mg J1599 Immune globulin, intravenous, non-lyophilized (e.g. liquid), not otherwise specified, 500 mg J1600 Gold sodium thiomalate, up to 50 mg J1602 Golimumab, per 1 mg for Intravenous use J1610 Glucagon HCl, per 1 mg J1620 Gonadorelin HCl, per 100 mcg J1626 Granisetron HCl, 100 mcg J1627 Granisetron, extended-release, 0.1 mg J1628 Guselkumab, 1 mg J1630 Haloperidol, up to 5 mg J1631 Haloperidol decanoate, per 50 mg J1642 Heparin sodium, (heparin lock flush), per 10 units J1644 Heparin sodium, per 1000 units J1645 Dalteparin sodium, per 2500 IU J1652 Fondaparinux sodium, 0.5 mg J1655 Tinzaparin sodium, 1000 IU J1710 Hydrocortisone sodium phosphate, up to 50 mg J1720 Hydrocortisone sodium succinate, up to 100 mg J1726 Injection, hydroxyprogesterone caproate, (Makena), 10 mg J1729 Injection, hydroxyprogesterone caproate, not otherwise specified, 10 mg J1730 Diazoxide, up to 300 mg J1738 Meloxicam, 1mg J1740 Ibandronate sodium, 1 mg J1741 Injection, ibuprofen, 100 mg J1745 Infliximab, 10 mg J1746 Ibalizumab-uiyk, 10 mg J1750 Iron dextran, 50 mg J1756 Iron sucrose, 1 mg J1786 Imiglucerase, 10 units J1790 Droperidol, up to 5 mg J1800 Propranolol HCl, up to 1 mg J1815 Insulin, per 5 units J1817 Insulin (i.e., insulin pump) per 50 units (Administered under direct physician supervision, not for self-administration) J1823 Inebilizumab-cdon, 1 mg J1826 Interferon beta-1a, 30 mcg J1830 Interferon beta-1b, 0.25 mg (Administered under direct physician supervision, not for self-administration) J1840 Kanamycin sulfate, up to 500 mg J1850 Kanamycin sulfate, up to 75 mg J1885 Ketorolac tromethamine, per 15 mg J1890 Cephalothin sodium, up to 1 gm J1930 Lanreotide, 1 mg Version 2021-2 Page 41 of 64 Nurse Practitioner Procedure Codes J1931 Laronidase, 0.1 mg J1940 Furosemide, up to 20 mg J1943 Aripiprazole lauroxil (aristada initio), 1 mg J1944 Aripiprazole lauroxil (aristada), 1 mg J1950 Leuprolide acetate (for depot suspension), per 3.75 mg J1955 Levocarnitine, per 1 gm J1960 Levorphanol tartrate, up to 2 mg J1980 Hyoscyamine sulfate, up to 0.25 mg J1990 Chlordiazepoxide HCl, up to 100 mg J2001 Lidocaine HCl for intravenous infusion, 10 mg J2010 Lincomycin HCl, up to 300 mg J2060 Lorazepam, 2 mg J2150 Mannitol, 25% in 50 ml J2175 Meperidine HCl, per 100 mg J2210 Methylergonovine maleate, up to 0.2 mg J2248 Micafungin sodium, 1 mg J2260 Milrinone lactate, per 5 mg J2270 Morphine sulfate, up to 10 mg J2274 Morphine sulfate, preservative-free for epidural or intrathecal use, 10 mg J2278 Ziconotide, 1 mcg J2310 Naloxone hydrochloride, per 1 mg J2320 Nandrolone decanoate, up to 50 mg J2323 Natalizumab, 1 mg J2350 Ocrelizumab, 1 mg J2353 Octreotide, depot form for intramuscular injection, 1 mg J2355 Oprelvekin, 5 mg J2357 Omalizumab, 5 mg J2358 Olanzapine, long-acting, 1 mg J2360 Orphenadrine citrate, up to 60 mg J2370 Phenylephrine HCl, up to 1 ml J2405 Ondansetron HCl, per 1 mg J2407 Oritavancin, 10 mg J2410 Oxymorphone HCl, up to 1 mg J2425 Palifermin, 50 mg J2426 Paliperidone palmitate extended release, 1 mg J2430 Pamidronate disodium, per 30 mg J2440 Papaverine HCl, up to 60 mg J2460 Oxytetracycline HCl, up to 50 mg J2469 Palonosetron HCl, 25 mcg J2502 Pasireotide long acting, 1 mg J2504 Pegademase bovine, 25 IU J2505 Pegfilgrastim, 6 mg J2510 Penicillin G procaine, aqueous, up to 600,000 units J2513 Pentastarch, 10% solution, 100 ml Version 2021-2 Page 42 of 64 Nurse Practitioner Procedure Codes J2515 Pentobarbital sodium, per 50 mg J2540 Penicillin G potassium, up to 600,000 units J2545 Pentamidine isethionate, inhalation solution, FDA-approved final product, non- compounded, administered through DME, unit dose form, per 300 mg J2550 Promethazine HCl, up to 50 mg J2560 Phenobarbital sodium, up to 120 mg J2590 Oxytocin, up to 10 units J2597 Desmopressin acetate, per 1 mcg J2650 Prednisolone acetate, up to 1 ml J2670 Tolazoline HCl, up to 25 mg J2675 Progesterone, per 50 mg J2680 Fluphenazine decanoate, up to 25 mg J2690 Procainamide HCl, up to 1 gm J2700 Oxacillin sodium, up to 250 mg J2710 Neostigmine methylsulfate, up to 0.5 mg J2720 Protamine sulfate, per 10 mg J2730 Pralidoxime chloride, up to 1 gm J2760 Phentolamine mesylate, up to 5 mg J2765 Metoclopramide HCl, up to 10 mg J2780 Ranitidine HCl, 25 mg J2783 Rasburicase, 0.5 mg J2794 Risperidone, (Risperdal consta), 0.5 mg J2796 Romiplostim, 10 micrograms J2797 Rolapitant, 0.5 mg J2798 Risperidone (perseris), 0.5 mg J2800 Methocarbamol, up to 10 ml J2820 Sargramostim (GM-CSF), 50 mcg J2860 Siltuximab, 10 mg J2910 Aurothioglucose, up to 50 mg J2916 Sodium ferric gluconate complex in sucrose injection, 12.5 mg J2920 Methylprednisolone sodium succinate, up to 40 mg¬ J2930 Methylprednisolone sodium succinate, up to 125 mg J2940 Somatrem, 1 mg J2941 Somatropin, 1 mg J2995 Streptokinase, per 250,000 IU J3000 Streptomycin, up to 1 gm J3030 Sumatriptan succinate, 6 mg J3031 Fremanezumab-vfrm, 1 mg (Administered under direct physician supervision, not for self-administration) J3032 Eptinezumab-jjmr, 1 mg J3060 Taliglucerace alfa, 10 units J3070 Pentazocine, 30 mg J3090 Tedizolid phosphate, 1 mg J3095 Televancin, 10 mg J3105 Terbutaline sulfate, up to 1 mg Version 2021-2 Page 43 of 64 Nurse Practitioner Procedure Codes J3111 J3121 J3145 J3230 J3240 J3241 J3245 J3250 J3260 J3262 J3265 J3280 J3285 J3300 J3301 J3302 J3303 J3305 J3310 J3315 J3316 J3320 J3357 J3358 J3360 J3364 J3370 J3380 J3397 J3400 J3410 J3411 J3415 J3420 J3430 J3470 J3475 J3480 J3489 J3490 J3520 J3590 J3591 Romosozumab-aqqg, 1 mg Testosterone, enanthate, 1 mg Testosterone, undecanoate, 1 mg Chlorpromazine HCl, up to 50 mg Thyrotropin alpha, 0.9 mg. provided in 1.1 mg Teprotumumab-trbw, 10 mg Tildrakizumab, 1 mg Trimethobenzamide HCl, up to 200 mg Tobramycin sulfate, up to 80 mg Tocilizumab, 1 mg Torsemide, 10 mg/ml Thiethylperazine maleate, up to 10 mg Treprostinil, 1 mg Triamcinolone acetonide, preservative free, 1 mg Triamcinolone acetonide, not otherwise specified, 10 mg Triamcinolone diacetate, per 5 mg Triamcinolone hexacetonide, per 5 mg Trimetrexate glucuronate, per 25 mg Perphenazine, up to 5 mg Triptorelin pamoate, 3.75 mg Triptorelin, extended-release, 3.75 mg Spectinomycin dihydrochloride, up to 2 gm Ustekinumab, for subcutaneous injection, 1 mg Ustekinumab, for intravenous injection, 1 mg Diazepam, up to 5 mg Urokinase, 5000 IU vial Vancomycin HCl, 500 mg Vedolizumab, 1 mg Vestronidase alfa-vjbk, 1 mg Triflupromazine HCl, up to 20 mg Hydroxyzine HCl, up to 25 mg Thiamine HCl, 100 mg Pyridoxine HCl, 100 mg Vitamin B-12 cyanocobalamin, up to 1000 mcg Phytonadione, (vitamin K), per 1 mg Hyaluronidase, up to 150 units Magnesium sulfate, per 500 mg Potassium chloride, per 2 meq Zoledronic acid, 1 mg Unclassified drugs Edetate disodium, per 150 mg Unclassified Biologics Unclassified drug or biological used for ESRD on dialysis MISCELLANEOUS DRUGS AND SOLUTIONS Version 2021-2 Page 44 of 64 Nurse Practitioner Procedure Codes Codes followed by an ^ do not require an NDC to be provided when billed. A4216^ Sterile water, saline and/or dextrose diluent/flush, 10 ml A4218^ Sterile saline or water, metered dose dispenser, 10 ml J7030 Infusion, normal saline solution (or water), 1000 cc J7040 Infusion, normal saline solution (or water), sterile (500 ml = 1 unit) J7042 5% dextrose/normal saline (500 ml = 1 unit) J7050 Infusion, normal saline solution (or water), 250 cc J7060 5% dextrose/water (500 ml = 1 unit) J7070 Infusion, D5W, 1000 cc J7100 Infusion, Dextran 40, 500 ml J7110 Infusion, dextran 75, 500 ml J7120 Ringers lactate infusion, up to 1000 cc J7121 5% Dextrose in lactated ringers infusion, up to 1000 cc J7131 Hypertonic saline solution, 1 ml J7296 Levonorgestrel-releasing intrauterine contraceptive system,(kyleena), 19.5 mg J7297 Levonorgestrel-releasing intrauterine contraceptive system, 52 mg, 3 year duration J7298 Levonorgestrel-releasing intrauterine contraceptive system, 52 mg, 5 year duration J7300 Intrauterine copper contraceptive J7301 Levonorgestrel-releasing intrauterine contraceptive system, 13.5 mg J7303 Contraceptive supply, hormone containing vaginal ring, each J7304 Contraceptive supply, hormone containing patch, each J7306 Levonorgestrel (contraceptive) implant system, including implants and supplies J7307 Etonogestrel (contraceptive) implant system, including implant and supplies J7308 Aminolevulinic acid HCl for topical administration, 20%, single unit dosage form (354 mg) J7321^ Hyaluronan or derivative, Hyalgan or Supartz,or visco-3, for intra-articular injection, per dose J7323^ Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose J7324^ Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose J7325^ Hyaluronan or derivative, Synvisc or Synvisc-One, intra-articular J7326 Hyaluronan or derivative, Gel-One, for intra-articular injection, per dose J7336 Capsaicin 8% patch, per square centimeter J7345 Aminolevulinic acid hcl for topical administration, 10% gel, 10 mg J7501 Azathioprine, parenteral (eg Imuran), 100 mg J7504 Lymphocyte immune globulin, antithymocyte globulin equine, parenteral, 250 mg J7606 Formoterol fumarate, inhalation solution, non-compounded, administered through DME, unit dose form, 20 mcg J7611 Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, 1mg J7612 Levalbuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, 0.5 mg J7613 Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 1 mg J7614 Levalbuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME. Unit dose. 0.5 mg Version 2021-2 Page 45 of 64 Nurse Practitioner Procedure Codes J7620 Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg, FDA-approved final product, non-compounded, administered through DME J7627 Budesonide, inhalation solution, compounded product, administered through DME, unit dose form, up to 0.5 mg J7628 Bitolterol mesylate, inhalation solution, compounded product, administered through DME, concentrated form, per mg J7631 Cromolyn sodium, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose form, per 10 mg J7640 Formoterol, inhalation solution, compounded product, administered through DME, unit dose form, 12 mcg J7644 Ipratropium bromide, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose form, per mg J7648 Isoetharine HCl, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, per mg J7649 Isoetharine HCl, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose form, per mg J7658 Isoproterenol HCl, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, per mg J7668 Metaproterenol sulfate, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, per 10 mg J7669 Metaproterenol sulfate, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose form, per 10 mg J7674 Methacholine chloride administered as inhalation solution through a nebulizer, per 1 mg J7682 Tobramycin, inhalation solution, FDA-approved final product, non-compounded, unit dose form, administered through DME, 300 mg J7999 Compounded drug, not otherwise classified J8501 Aprepitant, oral, 5 mg J8540 Dexamethasone, oral, 0.25 mg J8650 Nabilone, oral, 1 mg J9037 Belantamab mafodontin-BLMF, 0.5 mg J9226 Histrelin implant (Supprelin LA), 50 mg J9349 Tafasitamab-CXIX, 2 mg Q0138 Ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-ESRD use) Q5101 Filgrastim -sndz, biosimilar, (zarxio), 1 microgram Q5103 Inflectra (Infliximab-dyyb), biosimilar, 10 mg Q5104 Renflexis (Infliximab-abda), biosimilar, 10 mg Q5108 Pegfilgrastim-jmdb, biosimilar, 0.5 mg Q5111 Pegfilgrastim-cbqv, biosimilar, 0.5 mg Q5112 Trastuzumab-dttb, biosimilar, 10 mg Q5119 Rituximab-pvvr, biosimilar, 10 mg Q5120 Pegfilgrastim-bmez, biosimilar, 0.5 mg Q5121 Infliximab-axxq, biosimilar, 10 mg Q9991 Buprenorphone extended-release, less than or equal to 100 mg Q9992 Buprenorphone extended-release, greater than or 100 mg Version 2021-2 Page 46 of 64 Nurse Practitioner Procedure Codes HYDRATION, THERAPEUTIC, PROPHYLACTIC, DIAGNOSTIC INJECTIONS and INFUSIONS, and CHEMOTHERAPY and OTHER HIGHLY COMPLEX DRUG or HIGHLY COMPLEX BIOLOGIC AGENT ADMINISTRATION Physician work related to hydration, injection, and infusion services predominantly involves affirmation of treatment plan and direct supervision of staff. If a significant separately identifiable Evaluation and Management service is performed, the appropriate E/M service code should be reported using modifier `25' in addition to 96360-96549. For same day E/M service a different diagnosis is not required. If performed to facilitate the infusion or injection, the following services are included and are not reported separately: a. Use of local anesthesia b. IV start c. Access to indwelling IV, subcutaneous catheter or port d. Flush at conclusion of infusion e. Standard tubing, syringes, and supplies When multiple drugs are administered, report the service(s) and the specific materials or drugs for each. When administering multiple infusions, injections or combinations, only one "initial'' service code should be reported, unless protocol requires that two separate IV sites must be used. If an injection or infusion is of a subsequent or concurrent nature, even if it is the first such service within that group of services, then a subsequent or concurrent code from the appropriate section should be reported (eg, the first IV push given subsequent to an initial one-hour infusion is reported using a subsequent IV push code). When these codes are reported by the physician, the "initial'' code that best describes the key or primary reason for the encounter should always be reported irrespective of the order in which the infusions or injections occur. When reporting codes for which infusion time is a factor, use the actual time over which the infusion is administered. Intravenous or intra-arterial push is defined as: (a) an injection in which the health care professional who administers the substance/drug is continuously present to administer the injection and observe the patient, or (b) an infusion of 15 minutes or less. HYDRATION Codes 96360-96361 are intended to report a hydration IV infusion to consist of a pre-packaged fluid and electrolytes (eg, normal saline, D5-1/2 normal saline+30mEq KCl/liter), but are not used to report infusion of drugs or other substances. Hydration IV infusions typically require direct physician supervision for purposes of consent, safety oversight, or intraservice supervision of staff. Typically such infusions require little special handling to prepare or dispose of, and staff that administer these do not typically require advanced practice training. After initial set-up, infusion typically entails little patient risk and thus little monitoring. These codes are not intended to be reported by the physician in the facility setting. Version 2021-2 Page 47 of 64 Nurse Practitioner Procedure Codes 96360 96361 Intravenous infusion, hydration; initial, 31 minutes to 1 hour (Do not report 96360 if performed as a concurrent infusion service) (Do not report intravenous infusion for hydration of 30 minutes or less) each additional hour (List separately in addition to primary procedure) (Use 96361 in conjunction with 96360) (Report 96361 for hydration infusion intervals of greater than 30 minutes beyond 1 hour increments) (Report 96361 to identify hydration if provided as a secondary or subsequent service after a different initial service [96360, 96365, 96409, 96413] is administered through the same IV access) THERAPEUTIC, PROPHYLACTIC AND DIAGNOSTIC INJECTIONS AND INFUSIONS (EXCLUDES CHEMOTHERAPY AND OTHER HIGHLY COMPLEX DRUG OR HIGHLY COMPLEX BIOLOGIC AGENT ADMINISTRATION) A therapeutic, prophylactic or diagnosis IV infusion or injection (other than hydration) is for the administration of substances/drugs. When fluids are used to administer the drug(s), the administration of the fluid is considered incidental hydration and is not separately reportable. These services typically require direct physician supervision for any or all purposes of patient assessment, provision of consent, safety oversight, and intra-service supervision of staff. Typically, such infusions require special consideration to prepare, dose or dispose of, require practice training and competency for staff who administer the infusions, and require periodic patient assessment with vital sign monitoring during the infusion. These codes are not intended to be reported by the physician in the facility setting. (Do not report 96365-96371 with codes for which IV push or infusion is an inherent part of the procedure [eg, administration of contrast material for a diagnostic imaging study]) 96365 96366 96367 96368 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drugs); up to 1 hour each additional hour (List separately in addition to primary procedure) (Report 96366 in conjunction with 96365, 96367) (Report 96366 for additional hour[s] of sequential infusion) (Report 96366 for infusion intervals of greater than 30 minutes beyond 1 hour increments) additional sequential infusion of a new drug/substance, up to 1 hour (List separately in addition to primary procedure) (Report 96367 in conjunction with 96365, 96409, 96413 to identify the infusion of a new drug/substance provided as a secondary or subsequent service after a different initial service is administered through the same IV access. (Report 96367 only once per sequential infusion of same infusate mix) concurrent infusion (List separately in addition to primary procedure) (Report 96368 only once per encounter) Version 2021-2 Page 48 of 64 Nurse Practitioner Procedure Codes 96369 96370 96371 96372 (Report 96368 in conjunction with 96365, 96366, 96413, 96415, 96416) Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to 1 hour, including pump set-up and establishment of subcutaneous infusion site(s) each additional hour (List separately in addition to primary procedure) (Use 96370 in conjunction with 96369) (Use 96370 for infusion intervals of greater than 30 minutes beyond 1 hour increments) additional pump set-up with establishment of new subcutaneous infusion site(s) (List separately in addition to primary procedure) (Use 96371 in conjunction with 96369) (Use 96369, 96371 only once per encounter) Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular (Bill on one claim line for multiple injections) CHEMOTHERAPY AND OTHER HIGHLY COMPLEX DRUG OR HIGHLY COMPLEX BIOLOGIC AGENT ADMINISTRATION Procedures 96405-96549 are independent of the patient's office visit. Either may occur independently from the other on any given day, or they may occur sequentially on the same day. Intravenous chemotherapy injections are administered by a physician, a nurse practitioner or by a qualified assistant under supervision of the physician or nurse practitioner. Preparation of chemotherapy agent(s) is included in the service for administration of the agent. INJECTION AND INTRAVENOUS INFUSION CHEMOTHERAPY AND OTHER HIGHLY COMPLEX DRUG OR HIGHLY COMPLEX BIOLOGIC AGENT ADMINISTRATION 96405 96406 96409 96413 96415 96416 Chemotherapy administration; intralesional; up to and including 7 lesions intralesional, more than 7 lesions intravenous, push technique, single or initial substance/drug Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug (Report 96361 to identify hydration if administered as a secondary or subsequent service in association with 96413 through the same IV assess) (Report 96366, 96367, to identify therapeutic, prophylactic, or diagnostic drug infusion or injection, if administered as a secondary or subsequent service in association with 96413 through the same IV access) each additional hour (List separately in addition to primary procedure) (Use 96415 in conjunction with 96413) (Report 96415 for infusion intervals of greater than 30 minutes beyond 1-hour increments) initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump INTRA-ARTERIAL CHEMOTHERAPY AND OTHER HIGHLY COMPLEX DRUG OR HIGHLY COMPLEX BIOLOGIC AGENT ADMINISTRATION Version 2021-2 Page 49 of 64 Nurse Practitioner Procedure Codes 96420 Chemotherapy administration, intra-arterial; push technique 96422 infusion technique, up to 1 hour 96423 infusion technique, each additional hour (List separately in addition to primary procedure) (Use 96423 in conjunction with code 96422) (Report 96423 for infusion intervals of greater than 30 minutes beyond 1-hour increments) 96425 infusion technique, initiation of prolonged infusion (more than 8 hours), requiring the use of a portable or implantable pump OTHER INJECTION AND INFUSION SERVICES 96440 96446 96450 96521 96522 96542 96549 J9999 Chemotherapy administration into pleural cavity, requiring and including thoracentesis Chemotherapy administration into the peritoneal cavity via indwelling port or catheter Chemotherapy administration, into CNS (eg, intrathecal), requiring and including spinal puncture Refilling and maintenance of portable pump Refilling and maintenance of implantable pump or reservoir for drug delivery, systemic, (eg, intravenous, intra-arterial) Chemotherapy injection, subarachnoid or intraventricular via subcutaneous reservoir, single or multiple agents Unlisted chemotherapy procedure Not otherwise classified, antineoplastic drugs CHEMOTHERAPY DRUGS (Maximum fee is for chemotherapy drug only and does not include the administration procedures as listed above) NOTE: The maximum fees for these drugs are adjusted periodically by the State to reflect the estimated acquisition cost. Insert actual acquisition cost per dose in amount charged field on claim form. For codes listed BR/Report required, also attach itemized invoice to claim form. Reimbursement for drugs furnished by practitioners to their patients is based on the acquisition cost to the practitioner of the drug dose administered to the patient. For all drugs furnished in this fashion it is expected that the practitioner will maintain auditable records of the actual itemized invoice cost of the drug, including the numbers of doses of the drug represented on the invoice. New York State Medicaid does not intend to pay more than the acquisition cost of the drug dosage, as established by invoice, to the practitioner. Regardless of whether an invoice must be submitted to Medicaid for payment, the practitioner is expected to limit his or her Medicaid claim amount to the actual invoice cost of the drug dosage administered. Codes followed by an ^ do not require an NDC to be provided when billed. J9000 J9015 J9017 J9020 Doxorubicin HCL (Adriamycin), 10 mg Aldesleukin, per single use vial Arsenic trioxide, 1 mg (Trisenox) Asparaginase (Elspar) 10,000 units Version 2021-2 Page 50 of 64 Nurse Practitioner Procedure Codes J9022 Atezolizumab, 10 mg J9023 Avelumab, 10 mg J9025 Azacitidine, 1 mg J9027 Clofarabine, 1 mg J9030 BCG (intravesical) per 1mg J9032 Belinostat, 10 mg J9033 Bendamustine HCL (Treanda), 1 mg J9034 Bendamustine HCL (Bendeka), 1 mg J9035 Bevacizumab, 10 mg J9036 Bendamustine hydrochloride, 1 mg J9039 Blinatumomab, 1 microgram J9040 Bleomycin sulfate (Blenoxane), 15 units J9041 Bortezomib (velcade), 0.1 mg J9043 Carboplatin, 50 mg J9044 Bortezomib, not otherwise specified, 0.1 mg J9045 Carboplatin, 50 mg J9047 Carfilzomib, 1 mg J9050 Carmustine, 100 mg J9055 Cetuximab, 10 mg J9057 Copanlisib, 1 mg J9060 Cisplatin, powder or solution, 10 mg J9065 Cladribine, per 1 mg J9070 Cyclophosphamide, 100 mg J9098 Cytarabine liposome, 10 mg J9100 Cytarabine (Cytosar-U), 100 mg J9118 Calaspargase pegol-mknl, 10 units J9119 Cemiplimab-rwlc, 1 mg J9120 Dactinomycin (Cosmegen), 0.5 mg J9130 Dacarbazine, 100 mg J9144 Daratumumab, 10 mg and hyaluronidase-fihj J9145 Daratumumab, 10 mg J9150 Daunorubicin HCL, 10 mg J9151 Daunorubicin citrate, liposomal formulation, 10 mg J9153 Injection, liposomal, 1 mg daunorubicin and 2.27 mg cytarabine J9155 Degarelix, 1 mg J9160 Denileukin diftitox, 300 mcg J9165 Diethylstilbestrol diphosphate, 250 mg J9171 Docetaxel, 1 mg J9173 Injection, durvalumab, 10 mg J9176 Elotuzumab, 1 mg J9177 Enfortumab vedotin-ejfv 0.25mg J9178 Epirubicin HCL, 2 mg J9179 Eribulin mesylate, 0.1mg J9181 Etoposide, 10 mg J9185 Fludarabine phosphate, 50 mg Version 2021-2 Page 51 of 64 Nurse Practitioner Procedure Codes J9190 Fluorouracil, 500 mg J9198 Gemcitabine hydrochloride, (infugem), 100 mg J9199 Gemcitabine hydrochloride, 200 mg J9200 Floxuridine (FUDR), 500 mg J9201 Gemcitabine HCl, not otherwise specified, 200 mg J9202 Goserelin acetate implant per 3.6 mg J9203 Gemtuzumab ozogamicin, 0.1 mg J9204 Mogamulizumab-kpkc, 1 mg J9205 Irinotecan liposome, 1 mg J9206 Irinotecan, 20 mg J9207 Ixabepilone, 1 mg J9208 Ifosfamide, 1 gm J9209 Mesna, 200 mg J9210 Emapalumab-lzsg, 1 mg J9211 Idarubicin HCl, 5 mg J9212 Interferon Alfacon-1, Recombinant, 1 mcg J9213 Interferon, Alfa-2A, Recombinant, 3 million units J9214 Interferon, Alfa-2B, Recombinant, 1 million units J9215 Interferon, Alfa-N3, (Human Leukocyte Derived), 250,000 IU J9216 Interferon, Gamma 1-B, 3 million units J9217 Leuprolide acetate (for Depot Suspension), 7.5 mg J9218 Leuprolide acetate, per 1 mg J9219^ Leuprolide acetate implant, 65 mg J9223 Lurbinectedin, 0.1 mg J9225 Histrelin implant (Vantas), 50 mg J9227 Isatuximab-irfc, 10 mg J9228 Ipilimumab, 1mg J9229 Injection, inotuzumab ozogamicin, 0.1 mg J9230 Mechlorethamine HCl (nitrogen mustard), 10 mg J9245 Melphalan HCl, 50 mg J9246 Melphalan (evomela), 1 mg J9250 Methotrexate sodium, 5 mg J9260 Methotrexate sodium, 50 mg J9261 Nelarabine, 50 mg J9262 Omacetaxine mepesuccinate, 0.01 mg J9263 Oxaliplatin (Eloxatin), 0.5 mg J9264 Paclitaxel protein-bound particles, 1 mg J9266 Pegaspargase, per single dose vial J9267 Paclitaxel, 1 mg J9268 Pentostatin, per 10 mg J9269 Tagrxofusp-erzs, 10 micrograms J9270 Plicamycin, 2.5 mg J9271 Pembrolizumab, 1 mg J9280 Mitomycin, 5 mg J9281 Mitomycin pyelocalyceal instillation, 1 mg J9285 Olaratumab, 10 mg Version 2021-2 Page 52 of 64 Nurse Practitioner Procedure Codes J9293 Mitoxantrone HCl, per 5 mg J9295 Necitumumab, 1 mg J9299 Nivolumab, 1 mg J9301 Obinutuzumab, 10 mg J9302 Ofatumumab, 10 mg J9303 Panitumumab, 10 mg J9304 Pemetrexed (pemfexy), 10 mg J9305 Pemetrexed, 10 mg J9306 Pertuzumab, 1 mg J9307 Pralatrexate, 1 mg J9308 Ramucirumab, 5 mg J9309 Polatuzumab vedotin-piiq, 1 mg J9311 Injection, rituximab 10 mg and hyaluronidase J9312 Rituximab, 10 mg J9313 Moxetumomob pasudotox-tdfk, 0.01 mg J9315 Romidepsin, 1 mg J9316 Pertuzumab, trastuzumab, and hyaluronidase-zzxf, per 10 mg J9317 Sacituzumab govitecan-hziy, 2.5 mg J9320 Streptozocin, 1 gm J9325 Talimogene laherparepvec, per 1 million plaque forming units J9330 Temsirolimus, 1 mg J9340 Thiotepa, 15 mg J9351 Topotecan, 0.1 mg J9352 Trabectedin, 0.1 mg J9354 Ado-trastuzumab emtansine, 1 mg J9355 Trastuzumab, 10 mg J9356 Trastuzumab, 10 mg/Hyaluronidase-oysk J9357 Valrubicin, intravesical, 200 mg J9358 Fam-trastuzumab deruxtecan-nxki,1mg J9360 Vinblastine sulfate, 1 mg J9370 Vincristine sulfate, 1 mg J9371 Vincristine sulfate liposome, 1 mg J9390 Vinorelbine Tartrate, 10 mg J9395 Fulvestrant (Faslodex), 25 mg J9400 Ziv-aflibercept, 1 mg J9600 Porfimer sodium, 75 mg J9999 Not Otherwise Classified, Antineoplastic Drugs Q0174 Thiethylperazine Maleate, 10 mg, oral Q0177 Hydroxyzine Pamoate, 25 mg, oral Q2017 Teniposide, 50 mg Q2050 Doxorubicin HCL liposomal, NOS, 10 mg Q5107 Bevacizumab-awwb, biosimilar, 10 mg Q5113 Trastuzumab pkrb, biosimilar, 10 mg Q5114 Trastuzumab-dkst, biosimilar, 10 mg Q5115 Rituximab-abbs, biosimilar, 10 mg Q5116 Trastuzumab-qyyp, biosimilar, 10 mg Q5117 Trastuzumab-anns, biosimilar, 10 mg Q5118 Bevacizumab-bvzr, biosimilar, 10 mg Version 2021-2 Page 53 of 64 Nurse Practitioner Procedure Codes PSYCHIATRY Note: To bill for the following codes, you must be certified by the NYS Education Department as a Nurse Practitioner in Psychiatry (Profession Code 040) 90785 Interactive complexity (List separately in addition to primary procedure) 90791 Psychiatric diagnostic evaluation 90792 Psychiatric diagnostic evaluation with medical services PSYCHOTHERAPY 90832 90833 90834 90836 90837 90838 Psychotherapy, 30 minutes with patient Psychotherapy, 30 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure) Psychotherapy, 45 minutes with patient Psychotherapy, 45 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure) Psychotherapy, 60 minutes, with patient Psychotherapy, 60 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure) OTHER PSYCHOTHERAPY 90846 90847 90849 90853 Family psychotherapy (without the patient present), 50 minutes Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes Multiple-family group psychotherapy Group psychotherapy (other than of a multiple-family group) OTHER PSYCHIATRIC SERVICES OR PROCEDURES 90863 Pharmacologic management, including prescription and review of medication, when performed with psychotherapy services (List separately in addition to primary procedure) SPECIAL OPHTHALMOLOGICAL SERVICES 92071 Fitting of contact lens for treatment of ocular surface disease (Do not report 92071 in conjunction with 92072) Version 2021-2 Page 54 of 64 Nurse Practitioner Procedure Codes 92072 Fitting of contact lens for management of keratoconus, initial fitting (Do not report 92072 in conjunction with 92071) SPECIAL OTORHINOLARYNGOLOGIC SERVICES Diagnostic or treatment procedures that are reported as evaluation and management services (eg, otoscopy, anterior rhinoscopy, tuning fork test, removal of non-impacted cerumen) are not reported separately. Special otorhinolaryngologic services are those diagnostic and treatment services not included in an Evaluation and Management service. These services are reported separately, using codes 9250292700. VESTIBULAR FUNCTION TESTS, WITH RECORDING (eg, ENG) 92537 92538 92540 92541 92542 92544 92545 92546 92517 92518 92519 Caloric vestibular test with recording, bilateral; bithermal (ie, one warm and one cool irrigation in each ear for a total of four irrigations) monothermal (ie, one irrigation in each ear for a total of two irrigations) Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmus test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording Positional nystagmus test, minimum of 4 positions, with recording Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording Oscillating tracking test, with recording Sinusoidal vertical axis rotational testing Vestibular evoked myogenic potential (VEMP) testing, with interpretation and report; cervical (cVEMP) Ocular (oVEMP) Cervical (cVEMP) and ocular (oVEMP) AUDIOLOGIC FUNCTION TESTS The audiometric tests listed below require the use of calibrated electronic equipment, recording of results and a report with interpretation. Hearing tests (such as whispered voice, tuning fork) that are otorhinolaryngologic Evaluation and Management services are not reported separately. All services include testing of both ears. 92550 Tympanometry and reflex threshold measurements 92551 Screening test, pure tone, air only 92552 Pure tone audiometry (threshold); air only 92553 air and bone 92555 Speech audiometry threshold 92556 with speech recognition 92557 Comprehensive audiometry threshold evaluation and speech recognition (92553 and 92556 combined) Version 2021-2 Page 55 of 64 Nurse Practitioner Procedure Codes 92563 92565 92567 92568 92570 92571 92587 92650 92651 92652 92653 Tone decay test Stenger test, pure tone Tympanometry (impedance testing) Acoustic reflex testing; threshold Acoustic immittance testing, includes tympanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing Filtered speech test Distortion product evoked otoacoustic emissions; limited evaluation (to confirm the presence or absence of hearing disorder, 3-6 frequencies) or transient evoked otoacoustic emissions, with interpretation and report Auditory evoked potentials; screening of auditory potential with broadband stimuli, automated analysis for hearing status determination, broadband stimuli, with interpretation and report for threshold estimation at multiple frequencies, with interpretation and report neurodiagnostic, with interpretation and report CARDIOVASCULAR CARDIOGRAPHY 93000 Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report 93010 interpretation and report only PULMONARY Codes 94010-94799 include laboratory procedure(s) and interpretation of test results. 94010 94011 94012 94013 94014 94016 94060 94200 94644 94645 94664 Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation Measurement of spirometric forced expiratory flows in an infant or child through 2 years of age Measurement of spirometric forced expiratory flows, before and after bronchodilator, in an infant or child through 2 years of age Measurement of lung volumes (ie, functional residual capacity [FRC], forced vital capacity [FVC], and expiratory reserve volume [ERV] in an infant or child through 2 years of age Patient-initiated spirometric recording per 30-day period of time; includes reinforced education, transmission of spirometric tracing, data capture, analysis of transmitted data, periodic recalibration and physician review and interpretation physician review and interpretation only Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration Maximum breathing capacity, maximal voluntary ventilation Continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour each additional hour (List separately in addition to primary procedure) Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device (94664 can be reported one time only per day of service) Version 2021-2 Page 56 of 64 Nurse Practitioner Procedure Codes ALLERGY AND CLINICAL IMMUNOLOGY Immunotherapy (desensitization, hyposensitization) is the parenteral administration of allergenic extracts as antigens at periodic intervals, usually on an increasing dosage scale to a dosage which is maintained as maintenance therapy. Indications for immunotherapy are determined by appropriate diagnostic procedures coordinated with clinical judgment and knowledge of the natural history of allergic diseases. SENSITIVITY TESTING (Maximum fees include reading of test) 86580 Skin test; tuberculosis, intradermal ALLERGEN IMMUNOTHERAPY 95115 Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection 95117 2 or more injections ENDOCRINOLOGY 95250 Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; physician or other qualified healthcare professional (office) provided equipment, sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording 95251 analysis, interpretation and report MISCELLANEOUS SERVICES 93797 Physician services for outpatient cardiac rehabilitation; without continuous ECG monitoring (per session) 93798 with continuous ECG monitoring (per session) 95990 Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular), includes electronic analysis of pump, when performed 96040 Medical genetics and genetic counseling services, each 30 minutes face-to-face with patient/family 97542# Wheelchair management (eg, assessment, fitting, training), each 15 minutes (up to a maximum of 2 hours) 98960 Education and training for patient self-management by a qualified, non physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient 98961 2-4 patients 98962 5-8 patients 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 service Version 2021-2 Page 57 of 64 Nurse Practitioner Procedure Codes 99051 Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service 99070 Supplies and materials (except spectacles), provided by the physician over and above those usually included with the office visit or other services rendered (List drugs, trays, supplies, or materials provided) 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 to the physician or other qualified healthcare professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time, each 30 days 99170 Anogenital examination, magnified in childhood for suspected trauma, including image recording when performed 99188 Application of topical fluoride varnish by a physician or other qualified health care professional G0108 Diabetes outpatient self-management training services, individual, per 30 minutes G0109 group session (2 or more), per 30 minutes G0372 Physician service required to establish and document the need for a power mobility device G2082 Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care professional and provision of up to 56 mg of esketamine nasal self-administration, includes 2 hours post- administration observation G2083 Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care professional and provision of greater than 56 mg of esketamine nasal self-administration, includes 2 hours post-administration observation G8431 Screening for clinical depression is documented as being positive and a follow-up plan is documented G8510 Screening for clinical depression is documented as being negative, a follow-up plan is not required H0049 Alcohol and/or drug screening H0050 Alcohol and/or drug services, brief intervention, per 15 minutes Q3014 Telehealth originating site facility fee Q5106 Injection, epoetin alfa-epbx, biosimilar; (retacrit) (for non-ESRD use), 1000 units S0013 Esketamine, nasal spray, 1 mg S9445 Patient education, not otherwise classified, non-physician provider, individual, per session. (The initial lactation counseling session should be a minimum of 45 minutes. Follow up session(s) should be a minimum of 30 minutes.) S9446 Patient education, not otherwise classified, non-physician provider, individual, per session. (The initial lactation counseling session should be a minimum of 45 minutes. Follow up session(s) should be a minimum of 30 minutes.) NYS Medicaid will provide reimbursement for separate and distinct breastfeeding services provided by International Board Certified Lactation Consultants (IBCLCs) credentialed by the IBCLCE. For additional information see: http://www.health.ny.gov/health_care/medicaid/program/update/2013/2013-03.htm#fee Version 2021-2 Page 58 of 64 Nurse Practitioner Procedure Codes T1013 Sign language or oral interpretive services, per 15 minutes SURGERY SECTION GENERAL INFORMATION AND RULES 1. FEES: Fees for office, home and hospital visits and other medical services are listed in the section entitled MEDICINE. 2. FOLLOW UP (F/U) DAYS: Listed dollar values for all surgical procedures include the surgery and the follow-up care for the period indicated in days in the column headed "F/U Days". Necessary follow-up care beyond this listed period is to be added on a fee-for-service basis. (See modifier 24) 3. BY REPORT: When the value of a procedure is indicated as "By Report" (BR), an Operative Report must be submitted with the MMIS claim form for a payment determination to be made. The Operative Report must include the following information: a. Diagnosis (post-operative) b. Size, location and number of lesion(s) or procedure(s) where appropriate c. Major surgical procedure and supplementary procedure(s) d. Whenever possible, list the nearest similar procedure by number according to these studies e. Estimated follow-up period f. Operative time Failure to submit an Operative Report when billing for a "By Report" procedure will cause your claim to be denied by MMIS. 4. ADDITIONAL SERVICES: Complications or other circumstances requiring additional and unusual services concurrent with the procedure(s) or during the listed period of normal follow-up care may warrant additional charges on a fee-for-service basis. (See modifiers -24, -25, -79). When an additional surgical procedure(s) is carried out within the listed period of follow-up care for a previous surgery, the follow-up periods will continue concurrently to their normal terminations. 5. MULTIPLE SURGICAL PROCEDURES: a. When multiple or bilateral surgical procedures, which add significant time or complexity to patient care, are performed at the same operative session, the total dollar value shall be the value of the major procedure plus 50% of the value of the lesser procedure(s) unless otherwise specified. b. When an incidental procedure (eg, incidental appendectomy, lysis of adhesions, excision of previous scar, puncture of ovarian cyst) is performed through the same incision, the fee will be that of the major procedure only. 6. ASSIST AT SURGERY: When a physician requests a nurse practitioner or a physician's assistant to participate in the management of a specific surgical procedure in lieu of another physician, by prior agreement, the total value may be apportioned in relation to the responsibility and work Version 2021-2 Page 59 of 64 Nurse Practitioner Procedure Codes done, provided the patient is made aware of the fee distribution according to medical ethics. The value may be increased by 20 percent under these circumstances. The claim for these services will be submitted by the physician using the appropriate modifier. INTEGUMENTARY SYSTEM SKIN, SUBCUTANEOUS AND AREOLAR TISSUES INCISION AND DRAINAGE 10060 10061 10120 10140 10160 Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single complicated or multiple Incision and removal of foreign body, subcutaneous tissues; simple Incision and drainage of hematoma, seroma or fluid collection Puncture aspiration of abscess, hematoma, bulla, or cyst BIOPSY 11102 11103 11104 11105 11106 11107 Tangential biopsy of skin (eg, shave, scoop, saucerize, curette); single lesion each separate/additional lesion (List separately in addition to code for primary procedure) Punch biopsy of skin (including simple closure, when performed); single lesion each separate/additional lesion (List separately in addition to code for primary procedure) Incisional biopsy of skin (eg, wedge) (including simple closure, when performed); single lesion each separate/additional lesion (List separately in additional to code for primary procedure) REMOVAL OF SKIN TAGS Excision (including simple closure) of benign lesions of skin or subcutaneous tissues (eg, neoplasm, cicatricial, fibrous, inflammatory, congenital, cystic lesions), includes local anesthesia. See appropriate size and area below. 11200 Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions 11400 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less INTRODUCTION 11976 11981 11982 11983 Removal, implantable contraceptive capsules Insertion, non-biodegradable drug delivery implant Removal, non-biodegradable drug delivery implant Removal with reinsertion, non-biodegradable drug delivery implant REPAIR Version 2021-2 Page 60 of 64 Nurse Practitioner Procedure Codes Simple repair is used when the wound is superficial; eg, involving primarily skin and/or subcutaneous tissues without significant involvement of deeper structures, and requires simple one layer closure. FOR CLOSURE WITH ADHESIVE STRIPS, LIST APPROPRIATE EVALUATION AND MANAGEMENT SERVICE ONLY. Instructions for listing services at time of wound repair. 1. The repaired wound(s) should be measured and recorded in centimeters, whether curved, angular or stellate. 2. When multiple wounds are repaired, add together the lengths of those in the same classification (see above) and report as a single item. Simple ligation of vessels in an open wound is considered as part of any wound closure. Simple exploration of nerves, blood vessels or tendons exposed in an open wound is also considered part of the essential treatment of the wound and is not a separate procedure unless appreciable dissection is required. REPAIR-SIMPLE 12001 12002 12004 12005 12011 12013 12014 12015 12016 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less 2.6 cm to 7.5 cm 7.6 cm to 12.5 cm 12.6 cm to 20.0 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less 2.6 cm to 5.0 cm 5.1 cm to 7.5 cm 7.6 cm to 12.5 cm 12.6 cm to 20.0 cm BURNS, LOCAL TREATMENT Procedures 16000 and 16020 refer to local treatment of burned surface only. List percentage of body surface involved and depth of burn. For necessary related medical services (eg, hospital visits) in management of burned patients, see appropriate services in Medicine section. 16000 Initial treatment, first degree burn, when no more than local treatment is required 16020 Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area) DESTRUCTION 17000 17003 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); first lesion second through 14 lesions, each (List separately in addition to code for first lesion) Version 2021-2 Page 61 of 64 Nurse Practitioner Procedure Codes 17004 17106 17107 17108 17110 17111 17250 (Use 17003 in conjunction with 17000) Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses), 15 or more lesions (Do not report 17004 in conjunction with17000 -17003) Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq cm 10.0 to 50.0 sq cm over 50.0 sq cm Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions 15 or more lesions Chemical cauterization of granulation tissue (ie,proud flesh) DIGESTIVE SYSTEM STOMACH 43762 Replacement of gastrostomy tube, percutaneous, includes removal, when performed, without imaging or endoscopic guidance; not requiring revision of gastrostomy tract FEMALE GENITAL SYSTEM VULVA AND INTROITUS DESTRUCTION 56501 Destruction of lesion(s), vulva; simple (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) REPAIR 56820 Colposcopy of the vulva; VAGINA INTRODUCTION 57150 Irrigation of vagina and/or application of medicament for treatment of bacterial, parasitic, or fungoid disease ENDOSCOPY 57420 Colposcopy of the entire vagina, with cervix if present 57452 Colposcopy of the cervix including upper/adjacent vagina; 57454 with biopsy(s) of the cervix and endocervical curettage 57455 with biopsy(s) of the cervix 57456 with endocervical curettage Version 2021-2 Page 62 of 64 Nurse Practitioner Procedure Codes 57460 57461 57465 with loop electrode (biopsy(s) of the cervix with loop electrode conization of the cervix Computer-aided mapping of cervix uteri during colposcopy, including optical dynamic spectral imaging and algorithmic quantification of the acetowhitening effect (List separately in addition to code for primary procedure) CORPUS UTERI INTRODUCTION (For materials supplied by a practitioner, see General Information #7) 58300 Insertion of intrauterine device (IUD) 58301 Removal of intrauterine device (IUD) MATERNITY CARE Antepartum care includes usual prenatal services (initial and subsequent history, physical examinations, recording of weight, blood pressure, fetal heart tones, routine chemical urinalysis, maternity counseling). Postpartum care includes hospital and office visits following vaginal or cesarean section delivery. For medical complications of pregnancy (toxemia, cardiac problems, neurological problems or other problems requiring additional or unusual services or requiring hospitalization), see services in MEDICINE section. ANTEPARTUM AND POSTPARTUM CARE Reimbursement amounts for the Medicaid Obstetrical and Maternal Services Program (MOMS) are noted in the Enhanced Program Fee Schedule. For information on the MOMS Program see Policy Guidelines. 59412 External cephalic version, with or without tocolysis 59425 Antepartum care only; 4-6 visits 59426 7 or more visits (For 6 or less antepartum encounters, see code 59425) Note: Antepartum services will no longer require prorated charges. This applies to all prenatal care providers, including those enrolled in the MOMS program. Providers should bill one unit of the appropriate antepartum code after all antepartum care has been rendered using the last antepartum visit as the date of service. Only one antepartum care code will be reimbursed per pregnancy. 59430 Postpartum care only (separate procedure) (When inpatient postpartum care is provided, see appropriate Hospital Evaluation and Management code(s).) NERVOUS SYSTEM RESERVOIR/PUMP IMPLANTATION Version 2021-2 Page 63 of 64 Nurse Practitioner Procedure Codes 62367 62368 62369 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); without reprogramming or refilling with reprogramming with reprogramming and refill AUDITORY SYSTEM 69200 Removal foreign body from external auditory canal; without general anesthesia 69210 Removal impacted cerumen requiring instrumentation (report one unit for unilateral OR bilateral procedure.) Version 2021-2 Page 64 of 64Barbara J Heck Adobe PDF Library 21.5.80