HCPCSLevel II Expert

2016

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tIndex to Services, Supplies, Equipment, Drugs

Histrelin acetate - implant

Histrelin acetate J1675Histrelin implant J9225Hiv antigen/antibody screening G0298, G0475, S3645HKAFo (hip-knee-ankle-foot orthosis) L2040-L2090Holding chamber or spacer S8100, S8101Home care services S9097, S9098, S9110, S9122-S9131

Chore S5120-S5121Companion care S5135, S5136Foster care S5145, S5146Homemaker S5130, S5131Infusion therapy S9490Injection therapy S9537, S9542, S9558, S9559, S9560,

S9562INR monitoring G0248, G0249, G0250Irrigation therapy S9590Nurse practitioner S0274Other services S5165, S5170, S5175Pharmacy S9810Respiratory therapy S5180, S5181Respite care S5150, S5151, T1005Training S5108-S5116Transfusion S9538

Home health agency services T1022Home therapy and management services S0270-S0272,

S0280, S0281, S5522, S5523, S9208-S9379Home uterine monitor S9001Hospice and/or home health services

Aide G0156, T1004Assisted-living facility Q5002Care coordinator G9477Chaplain G9473Clinical social worker G0155Dietary counselor G9474Hospice facility Q5010Inpatient hospice facility Q5006Inpatient hospital Q5005Inpatient psychiatric facility Q5008Long term care facility Q5007Long-term care facility Q5003Not otherwise specified (NOS) Q5009Nursing G0128, G0162, G0163, G0164, G0299, G0300,

T1000, T1002, T1003Occupational therapy G0129, G0152, G0158, G0160Other counselor G9475Patient’s home Q5001Pharmacist G9479Physical therapy G0151, G0157, G0159Physician S0270, S0272, S0272, S0273Referral G9524, G9525, G9526, S0255Services T2042- T2048Skilled nursing facility Q5004Speech and language G0153, G0161Therapist G9478Volunteer G9476

Hospital servicesInpatient admissions G9521, G9522Observation/ED visit G0378-G0384

Hospitalist services S0310Hot water bottle A9273Hotline service, behavioral health H0030Human breast milk processing T2101Human fibrinogen concentrate J7178Humidifier A7046, E0550-E0562Hyalgan J7321Hyaluronan or derivative J7326, J7327, J7328, Q9980Hyaluronidase J3470

Ovine J3471, J3472, J3473Hydralazine Hcl J0360

Hydraulic patient lift E0630Hydrocollator E0225, E0239Hydrocolloid dressing A6234-A6241Hydrocortisone

Acetate J1700Sodium phosphate J1710Sodium succinate J1720

Hydrogel dressing A6231, A6232, A6233, A6242-A6248Hydromorphone J1170Hydromorphone hydrochloride S0092Hydroxyprogesterone caproate J1725Hydroxyurea, oral S0176Hydroxyzine Hcl J3410Hydroxyzine pamoate Q0177Hylan g-F 20 J7325Hyoscyamine sulfate J1980Hyperbaric oxygen treatment

Full body chamber G0277Topical A4575

Hypertonic saline solution J7131

Iibandronate sodium J1740ibuprofen J1741ibutilide fumarate J1742icatibant J1744ice cap or collar A9273idarubicin Hcl J9211idursulfase J1743ifosfamide J9208iloprost Q4074imaging

Angiography G0278Cardiac stress G8961-G8966Computed tomography (CT) S0832, S8092Echocardiography C8923-C8930Magnetic resonance (MRI) C1770, C8903-C8908, S8042Magnetic source S8035Mammography G0202, G0204, G0206PET scan G0219, G0235, G0252, S8085Ultrasound C1753, G0389, G8806, S8055, S9024

imatinib S0088imiglucerase J1786immune globulin

Bivigam™ J1556Flebogamma® J1572Gammagard® liquid J1569Gammaplex® J1557Gamunex® J1561HepaGam® B J1571Hizentra® J1559HyQvia® J1575Intravenous services, supplies and accessories Q2052Nonlyophilized, not otherwise specified (NOS) J1599Not otherwise specified (NOS) J1566Octagam® J1568Privigen® J1459Rho(D) J2788, J2790Rhophylac® J2791Subcutaneous J1562With hyaluronidase J1575

implantAccess system A4301Aqueous shunt L8612Auditory brain stem S2235Autologous cultured chondrocytes J7330

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l5699 - l5812Prosthetic Procedures (L5000-L9900)

prosTh

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l5699 - l5812

Male only Female only Age A2 - Z3 = ASC Payment Indicator A - Y = APC Status IndicatorASC = ASC Approved Procedure Paid under the DME fee schedule Physician Quality Reporting System

C L5699 All lower extremity prostheses, shoulder

harness A

REPLACEMENT SOCKETS (L5700-L5703)

C L5700 Replacement, socket, below knee, molded to

patient model A

C L5701 Replacement, socket, above knee/knee

disarticulation, including attachment plate,

molded to patient model A

C L5702 Replacement, socket, hip disarticulation,

including hip joint, molded to patient

model A

SACH Foot

C L5703 Ankle, Symes, molded to patient model,

socket without solid ankle cushion heel

(SACH) foot, replacement only A

CUSTOM-SHAPED PROTECTIVE COVERS (L5704-L5707)

C L5704 Custom shaped protective cover,

below knee A

C L5705 Custom shaped protective cover,

above knee A

C L5706 Custom shaped protective cover, knee

disarticulation A

C L5707 Custom shaped protective cover, hip

disarticulation A

EXOSKELETAL KNEE-SHIN SYSTEM ADDITIONS

(L5710-L5780)

C L5710 Addition, exoskeletal knee-shin system,

single axis, manual lock A

C L5711 Additions exoskeletal knee-shin system,

single axis, manual lock, ultra-light

material A

C L5712 Addition, exoskeletal knee-shin system,

single axis, friction swing and stance phase

control (safety knee) A

C L5714 Addition, exoskeletal knee-shin system,

single axis, variable friction swing phase

control A

C L5716 Addition, exoskeletal knee-shin

system, polycentric, mechanical stance

phase lock A

C L5718 Addition, exoskeletal knee-shin system,

polycentric, friction swing and stance phase

control A

C L5722 Addition, exoskeletal knee-shin system,

single axis, pneumatic swing, friction stance

phase control A

C L5724 Addition, exoskeletal knee-shin system,

single axis, fluid swing phase control A

C L5726 Addition, exoskeletal knee-shin system,

single axis, external joints fluid swing phase

control A

C L5728 Addition, exoskeletal knee-shin system,

single axis, fluid swing and stance phase

control A

C L5780 Addition, exoskeletal knee-shin system,

single axis, pneumatic/hydra pneumatic

swing phase control A

VACUUM PUMPS, LOWER LIMB PROSTHETIC ADDITIONS

(L5781, L5782)

C L5781 Addition to lower limb prosthesis, vacuum

pump, residual limb volume management

and moisture evacuation system A

C L5782 Addition to lower limb prosthesis,

vacuum pump, residual limb volume

management and moisture evacuation

system, heavy duty A

OTHER EXOSKELETAL ADDITIONS (L5785-L5795)

C L5785 Addition, exoskeletal system, below knee,

ultra-light material (titanium, carbon fiber or

equal) A

C L5790 Addition, exoskeletal system, above knee,

ultra-light material (titanium, carbon fiber or

equal) A

C L5795 Addition, exoskeletal system, hip

disarticulation, ultra-light material (titanium,

carbon fiber or equal) A

ENDOSKELETAL KNEE OR HIP SYSTEM ADDITIONS

(L5810-L5966)

C L5810 Addition, endoskeletal knee-shin system,

single axis, manual lock A

C L5811 Addition, endoskeletal knee-shin system,

single axis, manual lock, ultra-light

material A

C L5812 Addition, endoskeletal knee-shin system,

single axis, friction swing and stance phase

control (safety knee) A

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- t3 Appendix d: Ambulatory modifiers

Modifier Descriptor

25Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service

27 Multiple outpatient hospital E/M encounters on the same date

50 Bilateral procedure

52 Reduced services

58Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period

59 Distinct procedural service

73Discontinued out-patient hospital/ambulatory surgery center (ASC) procedure prior to the administration of anesthesia

74 Discontinued out-patient hospital/ambulatory surgery center (ASC) procedure after administration of anesthesia

76 Repeat procedure or service by same physician or other qualified health care professional

77 Repeat procedure by another physician or other qualified health care professional

78Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period

79Unrelated Procedure or service by the same physician or other qualified health care professional during the postoperative period

E1 Upper left, eyelid

E2 Lower left, eyelid

E3 Upper right, eyelid

E4 Lower right, eyelid

F1 Left hand, second digit

F2 Left hand, third digit

F3 Left hand, fourth digit

F4 Left hand, fifth digit

F5 Right hand, thumb

F6 Right hand, second digit

F7 Right hand, third digit

F8 Right hand, fourth digit

F9 Right hand, fifth digit

FA Left hand, thumb

GA Waiver of liability statement issued as required by payer policy, individual case

GC This service has been performed in part by a resident under the direction of a teaching physician

GEThis service has been performed by a resident without the presence of a teaching physician under the primary care exception

GV Attending physician not employed or paid under arrangement by the patient’s hospice provider

GW Service not related to the hospice patient’s terminal condition

LC Left circumflex coronary artery

LD Left anterior descending coronary artery

LT Left side (used to identify procedures performed on the left side of the body)

QM Ambulance service provided under arrangement by a provider of services

RC Right coronary artery

RT Right side (used to identify procedures performed on the right side of the body)

T1 Left foot, second digit

T2 Left foot, third digit

T3 Left foot, fourth digit

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