Never Pay Procedures Under APG Reimbursement

Revised for January 1, 2023 Updates:

Information revised during the quaterly update period stated above is highlighted.

Px Code Procedure (Px) Description Alternative
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20696 Comp multiplane ext fixation No 01/01/13    
20697 Comp ext fixate strut change No 01/01/13    
20983 Ablate bone tumor(s) perq No 07/01/16    
20985 Cptr-asst dir ms px No 12/01/08    
20986 Cptr-asst dir ms px io img No 12/01/08    
20987 Cptr-asst dir ms px pre img No 12/01/08    
22867 Insj stablj dev w/dcmprn No 01/01/17    
22868 Insj stablj dev w/dcmprn No 01/01/17    
22869 Insj stablj dev w/o dcmprn No 01/01/17    
22870 Insj stablj dev w/o dcmprn No 01/01/17    
27412 Autochondrocyte implant knee No 07/01/10    
28890 High energy eswt, plantar f No 12/01/08    
32994 Ablate pulm tumor perq crybl No 07/01/18    
36473 Endovenous mchnchem 1st vein No 01/01/17    
36474 Endovenous mchnchem add-on No 01/01/17    
36482 Endoven ther chem adhes 1st No 07/01/18    
36483 Endoven ther chem adhes sbsq No 07/01/18    
43257 Uppr gi scope w/thrml txmnt No 07/01/10    
43284 Laps esophgl sphnctr agmntj No 01/01/17    
43285 Rmvl esophgl sphnctr dev No 01/01/17    
55400 Repair of sperm duct No 04/01/13    
55706 Prostate saturation sampling No 07/01/10    
55874 Tprnl plmt biodegrdabl matrl No 07/01/18    
58750 Repair oviduct No 10/01/09    
59610 Vbac delivery No 01/01/20    
62380 Ndsc dcmprn 1 ntrspc lumbar No 01/01/17    
64912 Nrv rpr w/nrv algrft 1st No 07/01/18    
64913 Nrv rpr w/nrv algrft ea addl No 07/01/18    
65785 Impltj ntrstrml crnl rng seg No 01/01/18    
70554 Fmri brain by tech No 12/01/08    
74261 Ct colonography dx No 04/01/11    
74262 Ct colonography dx w/dye No 04/01/11    
74263 Ct colonography screening No 04/01/11    
75571 Ct hrt w/o dye w/ca test No 04/01/11    
75572 Ct hrt w/3d image No 04/01/11    
75573 Ct hrt w/3d image congen No 04/01/11    
75574 Ct angio hrt w/3d image No 04/01/11 07/01/16  
77082 Dxa bone density vert fx No 10/01/12 01/01/15  
77422 Neutron beam tx, simple No 04/01/09 07/01/10  
77423 Neutron beam tx, complex No 04/01/09 07/01/10  
81161 Dmd dup/delet analysis No 01/01/15    
81200 Aspa gene Yes 01/01/16    
81201 Apc gene full sequence Yes 01/01/16    
81202 Apc gene known fam variants Yes 01/01/16    
81203 Apc gene dup/delet variants Yes 01/01/16    
81205 Bckdhb gene Yes 01/01/16    
81206 Bcr/abl1 gene major bp Yes 01/01/16    
81207 Bcr/abl1 gene minor bp Yes 01/01/16    
81208 Bcr/abl1 gene other bp Yes 01/01/16    
81209 Blm gene Yes 01/01/16    
81210 Braf gene Yes 01/01/16    
81211 Brca1&2 seq & com dup/del Yes 01/01/16    
81212 Brca1&2 185&5385&6174 var Yes 01/01/16    
81213 Brca1&2 uncom dup/del var Yes 01/01/16    
81214 Brca1 full seq & com dup/del Yes 01/01/16    
81215 Brca1 gene known fam variant Yes 01/01/16    
81216 Brca2 gene full sequence Yes 01/01/16    
81217 Brca2 gene known fam variant Yes 01/01/16    
81220 Cftr gene com variants Yes 01/01/16    
81221 Cftr gene known fam variants Yes 01/01/16    
81222 Cftr gene dup/delet variants Yes 01/01/16    
81223 Cftr gene full sequence Yes 01/01/16    
81224 Cftr gene intron poly t Yes 01/01/16    
81225 Cyp2c19 gene com variants No 01/01/16    
81226 Cyp2d6 gene com variants Yes 01/01/16    
81227 Cyp2c9 gene com variants No 01/01/16    
81228 Cytogen micrarray copy nmbr Yes 01/01/16    
81229 Cytogen m array copy no&snp Yes 01/01/16    
81235 Egfr gene com variants Yes 01/01/16    
81240 F2 gene Yes 01/01/16    
81241 F5 gene Yes 01/01/16    
81242 Fancc gene Yes 01/01/16    
81243 Fmr1 gene detection Yes 01/01/16    
81244 Fmr1 gene characterization Yes 01/01/16    
81245 Flt3 gene Yes 01/01/16    
81246 Flt3 gene analysis No 01/01/16    
81250 G6pc gene Yes 01/01/16    
81251 Gba gene Yes 01/01/16    
81252 Gjb2 gene full sequence Yes 01/01/16    
81253 Gjb2 gene known fam variants Yes 01/01/16    
81254 Gjb6 gene com variants Yes 01/01/16    
81255 Hexa gene Yes 01/01/16    
81256 Hfe gene No 01/01/16    
81257 Hba1/hba2 gene Yes 01/01/16    
81260 Ikbkap gene Yes 01/01/16    
81261 Igh gene rearrange amp meth No 01/01/16    
81262 Igh gene rearrang dir probe No 01/01/16    
81263 Igh vari regional mutation No 01/01/16    
81264 Igk rearrangeabn clonal pop No 01/01/16    
81265 Str markers specimen anal No 01/01/16    
81266 Str markers spec anal addl No 01/01/16    
81267 Chimerism anal no cell selec No 01/01/16    
81268 Chimerism anal w/cell select No 01/01/16    
81270 Jak2 gene No 01/01/16    
81275 Kras gene Yes 01/01/16    
81280 Long qt synd gene full seq Yes 01/01/16    
81281 Long qt synd known fam var Yes 01/01/16    
81282 Long qt syn gene dup/dlt var Yes 01/01/16    
81287 Mgmt gene methylation anal Yes 01/01/16    
81288 Mlh1 gene No 01/01/16    
81290 Mcoln1 gene Yes 01/01/16    
81291 Mthfr gene No 01/01/16    
81292 Mlh1 gene full seq Yes 01/01/16    
81293 Mlh1 gene known variants Yes 01/01/16    
81294 Mlh1 gene dup/delete variant Yes 01/01/16    
81295 Msh2 gene full seq Yes 01/01/16    
81296 Msh2 gene known variants Yes 01/01/16    
81297 Msh2 gene dup/delete variant Yes 01/01/16    
81298 Msh6 gene full seq Yes 01/01/16    
81299 Msh6 gene known variants Yes 01/01/16    
81300 Msh6 gene dup/delete variant Yes 01/01/16    
81301 Microsatellite instability Yes 01/01/16    
81302 Mecp2 gene full seq Yes 01/01/16    
81303 Mecp2 gene known variant Yes 01/01/16    
81304 Mecp2 gene dup/delet variant Yes 01/01/16    
81310 Npm1 gene Yes 01/01/16    
81313 Pca3/klk3 antigen No 01/01/16    
81315 Pml/raralpha com breakpoints Yes 01/01/16    
81316 Pml/raralpha 1 breakpoint Yes 01/01/16    
81317 Pms2 gene full seq analysis Yes 01/01/16    
81318 Pms2 known familial variants Yes 01/01/16    
81319 Pms2 gene dup/delet variants Yes 01/01/16    
81321 Pten gene full sequence Yes 01/01/16    
81322 Pten gene known fam variant Yes 01/01/16    
81323 Pten gene dup/delet variant Yes 01/01/16    
81324 Pmp22 gene dup/delet No 01/01/16    
81325 Pmp22 gene full sequence No 01/01/16    
81326 Pmp22 gene known fam variant No 01/01/16    
81327 Sept9 methylation analysis N/A 01/01/17 07/01/18  
81330 Smpd1 gene common variants Yes 01/01/16    
81331 Snrpn/ube3a gene Yes 01/01/16    
81332 Serpina1 gene Yes 01/01/16    
81340 Trb@ gene rearrange amplify No 01/01/16    
81341 Trb@ gene rearrange dirprobe No 01/01/16    
81342 Trg gene rearrangement anal No 01/01/16    
81350 Ugt1a1 gene Yes 01/01/16    
81355 Vkorc1 gene Yes 01/01/16    
81370 Hla i & ii typing lr No 01/01/16    
81371 Hla i & ii type verify lr No 01/01/16    
81372 Hla i typing complete lr No 01/01/16    
81373 Hla i typing 1 locus lr No 01/01/16    
81374 Hla i typing 1 antigen lr No 01/01/16    
81375 Hla ii typing ag equiv lr No 01/01/16    
81376 Hla ii typing 1 locus lr No 01/01/16    
81377 Hla ii type 1 ag equiv lr No 01/01/16    
81378 Hla i & ii typing hr No 01/01/16    
81379 Hla i typing complete hr No 01/01/16    
81380 Hla i typing 1 locus hr No 01/01/16    
81381 Hla i typing 1 allele hr No 01/01/16    
81382 Hla ii typing 1 loc hr No 01/01/16    
81383 Hla ii typing 1 allele hr No 01/01/16    
81400 Mopath procedure level 1 Yes 01/01/16    
81401 Mopath procedure level 2 Yes 01/01/16    
81402 Mopath procedure level 3 Yes 01/01/16    
81403 Mopath procedure level 4 Yes 01/01/16    
81404 Mopath procedure level 5 Yes 01/01/16    
81405 Mopath procedure level 6 Yes 01/01/16    
81406 Mopath procedure level 7 Yes 01/01/16    
81407 Mopath procedure level 8 Yes 01/01/16    
81408 Mopath procedure level 9 Yes 01/01/16    
81410 Aortic dysfunction/dilation No 01/01/16    
81411 Aortic dysfunction/dilation No 01/01/16    
81415 Exome sequence analysis No 01/01/16    
81416 Exome sequence analysis No 01/01/16    
81417 Exome re-evaluation No 01/01/16    
81420 Fetal chrmoml aneuploidy Yes 01/01/16    
81422 Fetal chrmoml microdeltj N/A 01/01/17 07/01/18  
81425 Genome sequence analysis No 01/01/16    
81426 Genome sequence analysis No 01/01/16    
81427 Genome re-evaluation No 01/01/16    
81430 Hearing loss sequence analys No 01/01/16    
81431 Hearing loss dup/del analys No 01/01/16    
81435 Hereditary colon cancer No 01/01/16    
81436 Hereditary colon ca synd No 01/01/16    
81439 Inherited cardmypthy 5 gns N/A 01/01/17 07/01/18  
81440 Mitochondrial gene No 01/01/16    
81445 Targeted genomic seq analys No 01/01/16    
81450 Targeted genomic seq analys No 01/01/16    
81455 Targeted genomic seq analys No 01/01/16    
81460 Whole mitochondrial genome No 01/01/16    
81465 Whole mitochondrial genome No 01/01/16    
81470 X-linked intellectual dblt No 01/01/16    
81471 X-linked intellectual dblt No 01/01/16    
81479 Unlisted molecular pathology Yes 01/01/16    
81500 Onco (ovar) two proteins No 01/01/16    
81503 Onco (ovar) five proteins No 01/01/16    
81504 Oncology tissue of origin No 01/01/16    
81506 Endo assay seven anal No 01/01/16    
81507 Fetal aneuploidy trisom risk Yes 01/01/16    
81508 Ftl cgen abnor two proteins Yes 01/01/16    
81509 Ftl cgen abnor 3 proteins Yes 01/01/16    
81510 Ftl cgen abnor three anal Yes 01/01/16    
81511 Ftl cgen abnor four anal Yes 01/01/16    
81512 Ftl cgen abnor five anal Yes 01/01/16    
81519 Oncology breast mrna Yes 01/01/16    
81539 Oncology prostate prob score N/A 01/01/17 07/01/18  
81599 Unlisted maaa No 01/01/16    
83655 Assay of lead Yes 12/01/08    
83722 Lipoprtn dir meas sd ldl chl No 07/01/19    
83890 Molecule isolate Yes 01/01/10    
83891 Molecule isolate nucleic Yes 01/01/10    
83892 Molecular diagnostics Yes 01/01/10    
83893 Molecule dot/slot/blot Yes 01/01/10    
83894 Molecule gel electrophor Yes 01/01/10    
83896 Molecular diagnostics Yes 01/01/10    
83897 Molecule nucleic transfer Yes 01/01/10    
83898 Molecule nucleic ampli, each Yes 01/01/10    
83900 Molecule nucleic ampli 2 seq Yes 01/01/10    
83901 Molecule nucleic ampli addon Yes 01/01/10    
83902 Molecular diagnostics Yes 01/01/10    
83903 Molecule mutation scan Yes 01/01/10    
83904 Molecule mutation identify Yes 01/01/10    
83905 Molecule mutation identify Yes 01/01/10    
83906 Molecule mutation identify Yes 01/01/10    
83907 Lyse cells for nucleic ext Yes 01/01/10    
83908 Nucleic acid, signal ampli Yes 01/01/10    
83909 Nucleic acid, high resolute Yes 01/01/10    
83912 Genetic examination Yes 01/01/10    
83913 Molecular, rna stabilization Yes 01/01/10    
83914 Mutation ident ola/sbce/aspe Yes 01/01/10    
84410 Testosterone bioavailable N/A 01/01/17 07/01/18  
85004 Automated diff wbc count Yes 10/01/09    
85610 Prothrombin time Yes 10/01/09    
86008 Allg spec ige recomb ea Yes 07/01/18    
86328 Ia nfct ab sarscov2 covid 19 Yes 04/01/20    
86408 Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID19]); screen No 07/01/20    
86409 Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID19]); titer No 07/01/20    
86413 Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) antibody, quantitative Yes 07/01/20    
86769 Sars-cov-2 covid-19 antibody Yes 04/01/20    
86794 Zika virus igm antibody Yes 07/01/18    
86849 Immunology procedure Yes 04/01/12    
87426 Coronavirus ag ia Yes 04/01/20    
87483 Cns dna amp probe type 12-25 No 01/01/17    
87536 Hiv-1, dna, quant Yes 12/01/08    
87539 Hiv-2, dna, quant No 04/01/10    
87593 Orthopoxvirus amp prb each Yes 01/01/23    
87634 Rsv dna/rna amp probe Yes 07/01/18    
87635 Sars-cov-2 covid-19 amp prb Yes 01/01/20    
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 Yes 07/01/20    
87637 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), influenza virus types A and B, and respiratory syncytial virus, multiplex amplified probe technique Yes 07/01/20    
87662 Zika virus dna/rna amp probe Yes 07/01/18    
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]) Yes 07/01/20    
87900 Virtual phenotype Yes 01/01/10    
87901 GeNo - APG Carve Outtype, dna, hiv reverse t Yes 12/01/08    
87902 GeNo - APG Carve Outtype, dna, hepatitis C Yes 12/01/08    
87903 PheNo - APG Carve Outtype, dna hiv w/culture Yes 12/01/08    
87904 PheNo - APG Carve Outtype, dna hiv w/clt add Yes 10/01/09    
87913 Nfct agt gntyp alys sarscov2 Yes 01/01/21    
87999 Microbiology procedure Yes 12/01/08    
88230 Tissue culture, lymphocyte Yes 01/01/10    
88233 Tissue culture, skin/biopsy Yes 01/01/10    
88235 Tissue culture, placenta Yes 01/01/10    
88237 Tissue culture, bone marrow Yes 01/01/10    
88239 Tissue culture, tumor Yes 01/01/10    
88240 Cell cryopreserve/storage Yes 01/01/10    
88241 Frozen cell preparation Yes 01/01/10    
88245 Chromosome analysis, 20-25 Yes 01/01/10    
88248 Chromosome analysis, 50-100 Yes 01/01/10    
88249 Chromosome analysis, 100 Yes 01/01/10    
88261 Chromosome analysis, 5 No 01/01/10    
88262 Chromosome analysis, 15-20 Yes 01/01/10    
88263 Chromosome analysis, 45 Yes 01/01/10    
88264 Chromosome analysis, 20-25 No 01/01/10    
88267 Chromosome analys, placenta Yes 01/01/10    
88269 Chromosome analys, amniotic Yes 01/01/10    
88271 Cytogenetics, dna probe Yes 01/01/10    
88272 Cytogenetics, 3-5 Yes 01/01/10    
88273 Cytogenetics, 10-30 Yes 01/01/10    
88274 Cytogenetics, 25-99 Yes 01/01/10    
88275 Cytogenetics, 100-300 Yes 01/01/10    
88280 Chromosome karyotype study Yes 01/01/10    
88283 Chromosome banding study No 01/01/10    
88285 Chromosome count, additional Yes 01/01/10    
88289 Chromosome study, additional No 01/01/10    
88291 Cyto/molecular report Yes 01/01/10    
88299 Cytogenetic study No 01/01/16    
88323 Microslide consultation No 01/01/21    
88325 Comprehensive review of data No 01/01/21    
88331 Path consult intraop 1 bloc No 01/01/21    
88332 Path consult intraop addl No 01/01/21    
88333 Intraop cyto path consult 1 No 01/01/21    
88334 Intraop cyto path consult 2 No 01/01/21    
88375 Optical endomicroscpy interp No 01/01/21    
89250 Cultr oocyte/embryo <4 days No 01/01/21    
89251 Cultr oocyte/embryo <4 days No 01/01/21    
89253 Embryo hatching No 01/01/21    
89254 Oocyte identification No 01/01/21    
89255 Prepare embryo for transfer No 01/01/21    
89257 Sperm identification No 01/01/21    
89258 Cryopreservation embryo(s) No 01/01/21    
89259 Cryopreservation sperm No 01/01/21    
89260 Sperm isolation simple No 01/01/21    
89261 Sperm isolation complex No 01/01/21    
89264 Identify sperm tissue No 01/01/21    
89268 Insemination of oocytes No 01/01/21    
89272 Extended culture of oocytes No 01/01/21    
89280 Assist oocyte fertilization No 01/01/21    
89281 Assist oocyte fertilization No 01/01/21    
89290 Biopsy oocyte polar body No 01/01/21    
89291 Biopsy oocyte polar body No 01/01/21    
89335 Cryopreserve testicular tiss No 01/01/21    
89337 Cryopreservation oocyte(s) No 01/01/21    
89342 Storage/year embryo(s) No 01/01/21    
89343 Storage/year sperm/semen No 01/01/21    
89344 Storage/year reprod tissue No 01/01/21    
89346 Storage/year oocyte(s) No 01/01/21    
89352 Thawing cryopresrved embryo No 01/01/21    
89353 Thawing cryopresrved sperm No 01/01/21    
89354 Thaw cryoprsvrd reprod tiss No 01/01/21    
89356 Thawing cryopresrved oocyte No 01/01/21    
90375 Rabies ig im/sc Yes 07/01/17    
90376 Rabies ig heat treated Yes 07/01/17    
90470 H1N1 Administration Yes 10/01/09 07/01/11  
90473 Immune admin oral/nasal Yes 10/01/09 04/01/11  
90655 Flu vaccine no preserv 6-35m Yes 10/01/09 04/01/11  
90656 Flu vaccine no preserv 3 & > Yes 10/01/09 04/01/11  
90657 Flu vaccine, 3 yrs, im Yes 10/01/09 04/01/11  
90658 Flu vaccine, 3 yrs & >, im Yes 10/01/09 04/01/11  
90660 Flu vaccine, nasal Yes 10/01/09 04/01/11  
90663 Flu vacc pandemic Yes 10/01/09 07/01/11  
90669 Pneumococcal vacc, ped <5 Yes 10/01/09 04/01/11  
90732 Pneumococcal vaccine Yes 10/01/09 04/01/11  
90750 Hzv vacc recombinant im njx N/A 01/01/17 07/01/18  
90785 Psytx complex interactive No 01/01/21    
90863 Pharmacologic mgmt w/psytx No 04/01/13    
90875 Psychophysiological therapy No 07/01/10    
90876 Psychophysiological therapy No 07/01/10    
90880 Hypnotherapy No 04/01/09    
90901 Biofeedback train, any meth No 07/01/10    
90911 Biofeedback peri/uro/rectal No 07/01/10 01/01/20  
90951 Esrd serv 4 visits p mo <2yr No 01/01/20    
90952 Esrd serv 2-3 vsts p mo <2yr No 01/01/20    
90953 Esrd serv 1 visit p mo <2yrs No 01/01/20    
90954 Esrd serv 4 vsts p mo 2-11 No 01/01/20    
90955 Esrd srv 2-3 vsts p mo 2-11 No 01/01/20    
90956 Esrd srv 1 visit p mo 2-11 No 01/01/20    
90957 Esrd srv 4 vsts p mo 12-19 No 01/01/20    
90958 Esrd srv 2-3 vsts p mo 12-19 No 01/01/20    
90959 Esrd serv 1 vst p mo 12-19 No 01/01/20    
90960 Esrd srv 4 visits p mo 20+ No 01/01/20    
90961 Esrd srv 2-3 vsts p mo 20+ No 01/01/20    
90962 Esrd serv 1 visit p mo 20+ No 01/01/20    
90963 Esrd home pt serv p mo <2yrs No 01/01/20    
90964 Esrd home pt serv p mo 2-11 No 01/01/20    
90965 Esrd home pt serv p mo 12-19 No 01/01/20    
90966 Esrd home pt serv p mo 20+ No 01/01/20    
91300 SARSCOV2 VAC 30MCG/0.3ML IM Yes 01/01/21    
91301 SARSCOV2 VAC 100MCG/0.5ML IM Yes 01/01/21    
91302 SARSCOV2 VAC 5X10^10VP/.5MLIM No 01/01/21    
91303 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5x1010 viral particles/0.5mL dosage, for intramuscular use Yes 01/01/21    
91304 SARSCOV2 VAC 5MCG/0.5ML IM No 01/01/21    
91305 SARSCOV2 VAC 30 MCG TRS-SUCR No 01/01/21    
91306 SARSCOV2 VAC 50MCG/0.25ML IM No 01/01/21    
91307 vaccine (age 5-11) No 01/01/21    
91312 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 30 mcg/0.3 mL dosage, tris-sucrose formulation, for intramuscular use No 07/01/22    
91313 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, bivalent, preservative free, 50 mcg/0.5 mL dosage, for intramuscular use No 07/01/22    
91314 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, bivalent, preservative free, 25 mcg/0.25 mL dosage, for intramuscular use No 07/01/22    
91315 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, for intramuscular use No 07/01/22    
91316 Sarscov2 vac bvl 10mcg/0.2ml No 01/01/23    
91317 Sarscov2 vac bvl 3mcg/0.2ml No 01/01/23    
92145 Corneal hysteresis deter No 07/01/16    
92973 Prq coronary mech thrombect No 01/01/20    
93702 Bis xtracell fluid analysis No 07/01/16    
93895 Carotid intima atheroma eval No 07/01/16    
94664 Evaluate pt use of inhaler No 10/01/16    
95012 Exhaled nitric oxide meas No 12/01/08    
95800 Slp stdy unattended No 01/01/13    
95801 Slp stdy unatnd w/anal No 01/01/13    
95806 Sleep study unatt&resp efft No 01/01/13    
95965 Meg, spontaneous No 12/01/08 07/01/16  
95966 Meg, evoked, single No 12/01/08 07/01/16  
96102 Psycho testing by technician No 04/01/09 04/01/10  
96119 Neuropsych testing by tec No 04/01/09 04/01/10  
96127 Brief emotional/behav assmt No 07/01/16    
96131 Psycl tst eval phys/qhp ea No 07/01/19    
96133 Nrpsyc tst eval phys/qhp ea No 07/01/19    
96146 Psycl/nrpsyc tst auto result No 07/01/19    
96373 Ther/proph/diag inj ia No 01/01/20    
96374 Ther/proph/diag inj iv push No 01/01/20    
96375 Tx/pro/dx inj new drug addon No 01/01/20    
96376 Tx/pro/dx inj same drug adon No 01/01/20    
97012 Mechanical traction therapy No 04/01/13    
97124 Massage therapy No 04/01/09 07/01/10  
97150 Group therapeutic procedures No 04/01/09 04/01/10  
97169 Athletic trn eval low cmplx No 01/01/17    
97170 Athletic trn eval mod cmplx No 01/01/17    
97171 Athletic trn eval high cmplx No 01/01/17    
97172 Athletic trn re-eval plan cr No 01/01/17    
97610 Low frequency non-thermal us No 07/01/16    
97810 Acupunct w/o stimul 15 min No 04/01/09    
97811 Acupunct w/o stimul addl 15m No 04/01/09    
97813 Acupunct w/stimul 15 min No 04/01/09    
97814 Acupunct w/stimul addl 15m No 04/01/09    
98940 Chiropractic manipulation No 01/01/12    
98941 Chiropractic manipulation No 04/01/11    
98942 Chiropractic manipulation No 01/01/12    
98943 Chiropractic manipulation No 01/01/12    
99002 Device Handling No 04/01/11    
99072 Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other nonfacility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease No 07/01/20    
99453 Rem mntr physiol param setup No 01/01/23    
0001A ADM SARSCOV2 30MCG/0.3ML 1ST Yes 01/01/21    
0002A ADM SARSCOV2 30MCG/0.3ML 2ND Yes 01/01/21    
0003A ADM SARSCOV2 30MCG/0.3ML 3RD Yes 01/01/21    
0004A ADM SARSCOV2 30MCG/0.3ML BST Yes 01/01/21    
0004M Scoliosis dna alys No 01/01/16    
0006M Onc hep gene risk classifier No 01/01/16    
0006U Rx mntr 120+ drugs & sbsts No 07/01/18    
0007M Onc gastro 51 gene nomogram No 01/01/16    
0007U Rx test prsmv ur w/def conf No 07/01/18    
0008M Onc breast risk score No 01/01/16    
0008U Hpylori detcj abx rstnc dna No 07/01/18    
0009M Fetal aneuploidy trisom risk No 01/01/16 01/01/20  
0010M Onc Prostate prob score No 01/01/16    
0011A ADM SARSCOV2 100MCG/0.5ML1ST Yes 01/01/21    
0011U Rx mntr lc-ms/ms oral fluid No 07/01/18    
0012A ADM SARSCOV2 100MCG/0.5ML2ND Yes 01/01/21    
0013A ADM SARSCOV2 100MCG/0.5ML3RD Yes 01/01/21    
0019T Extracorp shock wv tx,ms nos No 04/01/10 1/1/17**  
0020U Rx test prsmv ur w/def conf No 07/01/18    
0021A ADM SARSCOV2 5X10^10VP/.5ML 1 No 01/01/21    
0022A ADM SARSCOV2 5X10^10VP/.5ML 2 No 01/01/21    
0031A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5x1010 viral particles/0.5mL dosage, single dose Yes 01/01/21    
0034A IMM ADMN SARSCOV2 AD26 5X1010 VP/0.5 ML BST DOSE Yes 01/01/21    
0038U Vitamin d srm microsamp quan No 07/01/19    
0041A ADM SARSCOV2 5MCG/0.5ML 1ST Yes 01/01/21    
0041U B brgdrferi antb 5 prtn igm No 07/01/19    
0042A ADM SARSCOV2 5MCG/0.5ML 2ND Yes 01/01/21    
0042U B brgdrferi antb 12 prtn igg No 07/01/19    
0043U Tbrf b grp antb 4 prtn igm No 07/01/19    
0044U Tbrf b grp antb 4 prtn igg No 07/01/19    
0051A ADM SARSCV2 30MCG TRS-SUCR 1 Yes 01/01/21    
0052A ADM SARSCV2 30MCG TRS-SUCR 2 Yes 01/01/21    
0053A ADM SARSCV2 30MCG TRS-SUCR 3 Yes 01/01/21    
0054A ADM SARSCV2 30MCG TRS-SUCR B Yes 01/01/21    
0058U Onc merkel cll carc srm quan No 07/01/19    
0059U Onc merkel cll carc srm +/- No 07/01/19    
0061U Tc meas 5 bmrk sfdi m-s alys No 07/01/19    
0064A ADM SARSCOV2 50MCG/0.25MLBST Yes 01/01/21    
0064U Antb tp total&rpr ia qual No 07/01/19    
0066U Pamg-1 ia cervico-vag fluid No 07/01/19    
0071A 1st dose Yes 01/01/21    
0072A 2nd dose Yes 01/01/21    
0077U Ig paraprotein qual bld/ur No 07/01/19    
0081A ADM SARSCOV2 3 MCG/0.2 ML TRS-SUCR 1st dose Yes 07/01/22    
0082A ADM SARSCOV2 3 MCG/0.2 ML TRS-SUCR 2nd dose Yes 07/01/22    
0083A ADM SARSCOV2 3 MCG/0.2 ML TRS-SUCR 3rd dose Yes 07/01/22    
0086U Nfct ds bact&fng org id 6+ No 07/01/20    
0091A ADM SARSCOV2 50 MCG/.5 ML 1st dose Yes 07/01/22    
0091U Onc clrct scr whl bld alg No 07/01/20    
0092A ADM SARSCOV2 50 MCG/.5 ML 2nd dose Yes 07/01/22    
0093A ADM SARSCOV2 50 MCG/.5 ML 3rd dose Yes 07/01/22    
0094A Moderna – ADM SARSCOV2 N/A 50MCG/0.5 ML – Booster Dose No 07/01/22    
0096U Hpv hi risk types male urine No 07/01/20    
0097U Gi pathogen 22 targets No 07/01/20    
0098U Respir pathogen 14 targets No 07/01/20    
0099U Respir pathogen 20 targets No 07/01/20    
0100U Respir pathogen 21 targets No 07/01/20    
0106U Gstr emptg 7 timed brth spec No 07/01/20    
0109U Id aspergillus dna 4 species No 07/01/20    
0111A ADM SARSCOV2 25MCG/0.25ML 1st dose Yes 07/01/22    
0112A ADM SARSCOV2 25MCG/0.25ML 2nd dose Yes 07/01/22    
0112U Iadi 16s&18s rrna genes No 07/01/20    
0113A ADM SARSCOV2 25MCG/0.25ML 3rd dose Yes 07/01/22    
0115U Respir iadna 18 viral&2 bact No 07/01/20    
0119U Crd ceramides liq chrom plsm No 01/01/22    
0121U Sc dis vcam-1 whole blood No 07/01/20    
0122U Sc dis p-selectin whl blood No 07/01/20    
0124A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 30 mcg/0.3 mL dosage, tris-sucrose formulation, booster dose Yes 07/01/22    
0126T Chd risk imt study No 01/01/13    
0134A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, bivalent, preservative free, 50 mcg/0.5 mL dosage, booster dose Yes 07/01/22    
0140U Nfct ds fungi dna 15 trgt No 07/01/20    
0141U Nfct ds bact&fng gram pos No 07/01/20    
0142U Nfct ds bact&fng gram neg No 07/01/20    
0143U Drug assay 120+ rx/metablt No 07/01/20    
0144A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRN-LNP, spike protein, bivalent, preservative free, 25 mcg/0.25 mL dosage, booster dose No 07/01/22    
0144U Drug assay 160+ rx/metablt No 07/01/20    
0145U Drug assay 65+ rx/metablt No 07/01/20    
0146U Drug assay 80+ rx/metablt No 07/01/20    
0147U Drug assay 85+ rx/metablt No 07/01/20    
0148U Drug assay 100+ rx/metablt No 07/01/20    
0149U Drug assay 60+ rx/metablt No 07/01/20    
0150U Drug assay 120+ rx/metablt No 07/01/20    
0151U Nfct bct/vir resp nfctj 33 No 07/01/20    
0152U Nfct bct fng prst dna >1000 No 07/01/20    
0154A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, booster dose No 07/01/22    
0164A Adm srscv2 bvl 10mcg/0.2ml b No 01/01/23    
0173A Adm sarscv2 bvl 3mcg/0.2ml 3 Yes 01/01/23    
0216T Njx paravert w/us lumb/sac No 01/01/13    
0217T Njx paravert w/us lumb/sac No 01/01/13    
0218T Njx paravert w/us lumb/sac No 01/01/13    
0223U Nfct ds 22 trgt sars-cov-2 Yes 04/01/20    
0224U Antibody sars-cov-2 titer(s) Yes 04/01/20    
0225U Infectious disease (bacterial or viral respiratory tract infection) pathogen-specific DNA and RNA, 21 targets, including severe acute respiratory syndrome coronavirus 2 (SARSCoV-2), amplified probe technique, including multiplex reverse transcription for RNA targets, each analyte reported as detected or not detected No 07/01/20    
0226U Surrogate viral neutralization test (sVNT), severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), ELISA, plasma, serum No 07/01/20    
0227U RX ASY PRSMV30+RX/METABLT No 01/01/21    
0240U Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 3 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B), upper respiratory specimen, each pathogen reported as detected or not detected No 07/01/20    
0241U Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 4 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B, respiratory syncytial virus [RSV]), upper respiratory specimen, each pathogen reported as detected or not detected No 07/01/20    
0310T Motor function mapping ntms No 04/01/13    
0311T Cal & alys cntrl artl press No 04/01/13    
0500T Hpv 5+ hi risk hpv types No 01/01/22    
1000F Tobacco use assessed No 12/01/08    
4000F Tobacco use txmnt counseling No 12/01/08    
A4459 Manual pump enema, reusable No 07/01/16    
A9699 Radiopharm rx agent noc Yes 01/01/23    
C9055 Injection, brexanolone, 1mg No 01/01/20 10/01/20  
C9137 Adynovate Factor VIII recom No 07/01/16 1/1/17**  
C9138 Nuwiq Factor VIII recomb No 07/01/16 1/1/17**  
C9140 Afstyla factor viii recomb No 01/01/18    
C9257 Bevacizumab injection No 01/01/18    
C9259 Injection, pralatrexate, 1 mg Yes 01/01/11    
C9287 Inj, brentuximab vedotin Yes 07/01/12    
C9471 Hymovis, 1 mg No 07/01/16 1/1/17**    
C9716 Radiofrequency energy to anu No 07/01/10    
C9803 Hopd covid-19 spec collect No 01/01/20    
D0414 Lab process microbial spec No 01/01/17    
D0421 Gen tst suscept oral disease Yes 01/01/16    
D0484 Consult slides prep elsewher No 01/01/21    
D0485 Consult inc prep of slides No 01/01/21    
D0600 Non-ionizing diag proc No 01/01/17    
D0601 Caries risk assess low risk No 01/01/21    
D0602 Caries risk assess mod risk No 01/01/21    
D0603 Caries risk assess high risk No 01/01/21    
D1354 Int caries med app per tooth No 01/01/18 01/01/21  
D1575 Dist space maint, fixed unil N/A 01/01/17 07/01/18  
D1999 Unspecified preventive proc No 01/01/21    
D4346 Scaling gingiv inflammation N/A 01/01/17 07/01/18  
D6080 Implant maintenance No 01/01/23    
D6081 Scale & debride, single imp N/A 01/01/17 07/01/18  
D6085 Provisional implant crown No 01/01/17    
D6092 Recement supp crown Yes 01/01/23    
D6093 Recement supp part denture Yes 01/01/23    
D6096 Remove broken imp ret screw Yes 01/01/23    
D6101 Debridement of a periimplant Yes 01/01/23    
D6102 Debridement & contouring Yes 01/01/23    
D6190 Radio/surgical implant index Yes 01/01/23    
D8695 Remove fixed ortho appliance Yes 01/01/23    
D8696 Rep of ortho appliance max No 01/01/23    
D8697 Rep of ortho appliance man No 01/01/23    
D8698 Recement fixed retainer max No 01/01/23    
D8699 Recement fixed retainer man No 01/01/23    
D8701 Repair fixed retainer max No 01/01/23    
D8702 Repair of fixed retainer man No 01/01/23    
D8703 Replace broken retainer max Yes 01/01/23    
D8704 Replace broken retainer man Yes 01/01/23    
D9210 Dent anesthesia w/o surgery No 01/01/16    
D9211 Regional block anesthesia No 01/01/16    
D9212 Trigeminal block anesthesia No 01/01/16    
D9215 Local anesthesia No 01/01/16    
D9220 General anesthesia No 01/01/18    
D9221 General anesthesia ea ad 15m No 07/01/11    
D9241 Intravenous sedation No 01/01/18    
D9242 IV sedation ea ad 30 m No 07/01/11    
D9311 Consult w/med hlth care prof No 01/01/17    
D9920 Behavior management No 12/01/08 07/01/11 07/01/20
D9991 Case mgmt, appt barriers No 01/01/17    
D9992 Case mgmt, care coordination No 01/01/17    
D9993 Case mgmt, interviewing No 01/01/17    
D9994 Case mgmt, pt education No 01/01/17    
D9995 Teledentistry real-time No 01/01/20    
D9996 Teledentistry dent review No 01/01/20    
G0008 Admin influenza virus vac Yes 10/01/09 04/01/11  
G0009 Admin pneumococcal vaccine Yes 10/01/09 04/01/11  
G0398 Home sleep test/type 2 Porta No 01/01/13    
G0399 Home sleep test/type 3 Porta No 01/01/13    
G0400 Home sleep test/type 4 Porta No 01/01/13    
G0464 Colorec ca scr, sto bas dna Yes 01/01/16    
G0493 Rn care ea 15 min hh/hospice No 01/01/17    
G0494 Lpn care ea 15min hh/hospice No 01/01/17    
G0495 Rn care train/edu in hh No 01/01/17    
G0496 Lpn care train/edu in hh No 01/01/17    
G2025 Dis site tele svcs rhc/fqhc No 01/01/20    
G8402 Smoke preven interven counse No 12/01/08    
G8403 Smoke preven Outcounsel No 12/01/08    
G9013 Esrd demo bundle level i No 01/01/20    
G9014 Esrd demo bundle-level ii No 01/01/20    
G9016 Demo-smoking cessation coun No 12/01/08    
G9141 Influenza A (H1N1) - administration No 10/01/09 07/01/11  
G9142 Influenza A (H1N1) - vaccine No 10/01/09 07/01/11  
G9143 Warfarin respon genetic test Yes 01/01/16    
G9481 Remote E/M new pt 10mins No 07/01/16    
G9482 Remote E/M new pt 20mins No 07/01/16    
G9483 Remote E/M new pt 30mins No 07/01/16    
G9484 Remote E/M new pt 45mins No 07/01/16    
G9485 Remote E/M new pt 60mins No 07/01/16    
G9486 Remote E/M est. pt 10mins No 07/01/16    
G9487 Remote E/M est. pt 15mins No 07/01/16    
G9488 Remote E/M est. pt 25mins No 07/01/16    
G9489 Remote E/M est. pt 40mins No 07/01/16    
G9490 Joint replac mod home visit No 07/01/16    
G9678 Oncology Care Model service No 07/01/16    
H0018 Alcohol and/or drug services No 07/01/10    
H0023 Behavioral health outreach service - planned approach to reach a targeted population No 10/01/10    
H0031 Mh health assess by non-md No 01/01/20    
H0032 MH svc plan dev by non-md No 07/01/10    
H0037 Comm psy sup tx pgm per diem No 07/01/10    
H0046 Mental health service, nos No 01/01/20    
H2029 Sex offend tx svc, per diem No 07/01/10    
J0128 Injection, abarelix, 10 mg Yes 01/01/11    
J0207 Amifostine Yes 07/01/21    
J0365 Injection, aprotonin, 10,000 kiu Yes 01/01/11    
J0480 Injection, basiliximab, 20 mg Yes 01/01/11    
J0585 Botulinum toxin a per unit Yes 12/01/08 01/01/15  
J0587 Botulinum toxin type B Yes 12/01/08    
J0740 Injection, cidofovir, 375 mg Yes 01/01/11    
J0882 Darbepoetin alfa, esrd use Yes 12/01/08 01/01/12  
J0886 Epoetin alfa 1000 units ESRD Yes 12/01/08 01/01/12 10/01/13
J0890 Peginesatide injection No 07/01/13    
J0894 Decitabine injection Yes 01/01/22    
J1322 Elosulfase alfa, injection Yes 01/01/22    
J1440 Filgrastim 300 mcg injection Yes 12/01/08    
J1441 Filgrastim 480 mcg injection Yes 12/01/08    
J1442 Inj filgrastim excl biosimil Yes 01/01/18    
J1566 Injection, immune globulin, intravenous, lyophilized (e.g. powder), not otherwise specified, 500 mg Yes 01/01/11    
J1675 Injection, histrelin acetate, 10 micrograms Yes 01/01/11    
J1725 Hydroxyprogesterone caproate Yes 04/01/12    
J1726 Makena, 10 mg Yes 01/01/18    
J1931 Injection, laronidase, 0.1 mg Yes 01/01/11    
J1950 Leuprolide acetate /3.75 mg Yes 01/01/22    
J2315 Naltrexone, depot form Yes - Only for Article 32 providers 01/01/10 07/01/11  
J2323 Natalizumab injection Yes - only for TOUCH providers 01/01/10 01/01/11  
J2358 Olanzapine long-acting inj Yes 04/01/11    
J2426 Paliperidone palmitate inj Yes 04/01/11    
J2505 Injection, pegfilgrastim 6mg Yes 12/01/08    
J2506 Inj pegfilgrast ex bio 0.5mg Yes 01/01/22    
J2562 Injection, plerixafor, 1 mg Yes 01/01/11    
J2783 Rasburicase Yes 01/01/21    
J2794 Risperidone, long acting Yes 04/01/09    
J2997 Alteplase recombinant Yes 04/01/10 04/01/11  
J3110 Injection, teriparatide, 10 mcg Yes 01/01/11    
J3285 Injection, treprostinil, 1 mg Yes 01/01/11    
J3316 Inj., triptorelin xr 3.75 mg Yes 01/01/22    
J3490 Drugs unclassified injection Yes 04/01/10    
J3590 Unclassified biologics Yes 04/01/10    
J7175 Inj, factor x, (human), 1iu Yes 01/01/18    
J7178 Human fibrinogen conc inj Yes 01/01/18    
J7179 Vonvendi inj 1 iu vwf:rco Yes 01/01/18    
J7180 Factor xiii anti-hem factor Yes 01/01/21    
J7181 Factor xiii recomb a-subunit Yes 01/01/18    
J7182 Factor viii recomb novoeight Yes 01/01/18    
J7183 Wilate injection Yes 01/01/18    
J7185 Xyntha inj Yes 01/01/18    
J7186 Antihemophilic viii/vwf comp Yes 01/01/18    
J7187 Humate-P, inj Yes 12/01/08    
J7188 Factor viii recomb obizur Yes 01/01/18    
J7189 Factor viia Yes 12/01/08    
J7190 Factor viii Yes 12/01/08    
J7191 Factor VIII (porcine) Yes 12/01/08    
J7192 Factor viii recombinant Yes 12/01/08    
J7193 Factor IX No - APG Carve Outn-recombinant Yes 12/01/08    
J7194 Factor ix complex Yes 12/01/08    
J7195 Factor IX recombinant Yes 12/01/08    
J7196 Antithrombin recombinant Yes 01/01/18    
J7197 Antithrombin iii injection Yes 12/01/08    
J7198 Anti-inhibitor Yes 12/01/08    
J7199 Hemophilia clot factor No - APG Carve Outc Yes 12/01/08    
J7200 Factor ix recombinan rixubis Yes 01/01/18    
J7201 Factor ix alprolix recomb Yes 01/01/18    
J7202 Factor ix idelvion inj Yes 01/01/18    
J7203 Factor ix recomb gly rebinyn Yes 01/01/21    
J7204 Inj recombin esperoct per iu Yes 01/01/21    
J7205 Factor viii fc fusion recomb Yes 01/01/18    
J7207 Factor viii pegylated recomb Yes 01/01/18    
J7208 Inj. jivi 1 iu Yes 01/01/21    
J7209 Factor viii nuwiq recomb 1iu Yes 01/01/18    
J7210 Inj, afstyla, 1 i.u. Yes 01/01/21    
J7211 Inj, kovaltry, 1 i.u. Yes 01/01/21    
J7294 Seg acet and eth estr yearly Yes 01/01/22    
J7295 Eth estr and eton monthly Yes 01/01/22    
J7296 Kyleena, 19.5 mg Yes 01/01/18    
J7297 Levonorgestrel iu 52mg 3 yr Yes 07/01/16    
J7298 Levonorgestrel iu 52mg 5 yr Yes 07/01/16    
J7300 Intraut copper contraceptive Yes 12/01/08    
J7301 Levonorgestrel iu 13.5 mg Yes 07/01/16    
J7302 LevoNo - APG Carve Outrgestrel iu contracept Yes 12/01/08    
J7306 Levonorgestrel implant sys Yes 07/01/16    
J7307 EtoNo - APG Carve Outgestrel implant system Yes 12/01/08    
J7311 Inj., retisert, 0.01 mg Yes 07/01/21    
J7320 Genvisc 850, inj, 1mg No 01/01/17    
J7322 Hymovis injection 1 mg No 01/01/17    
J8520 Capecitabine, oral, 150 mg Yes 01/01/11    
J9001 Injection, doxorubicin hydrochloride, all lipid formulations, 10 mg Yes 01/01/11    
J9019 Erwinaze injection Yes 07/01/14    
J9022 Inj, atezolizumab,10 mg Yes 01/01/21    
J9023 Injection, avelumab, 10 mg Yes 01/01/21    
J9027 Clofarabine injection Yes 12/01/08    
J9032 Injection, belinostat, 10mg Yes 01/01/21    
J9033 Injection, bendamustine hcl, 1 mg Yes 01/01/11    
J9034 Inj., bendeka 1 mg Yes 01/01/21    
J9035 Injection, bevacizumab, 10 mg Yes 01/01/11    
J9036 Inj. belrapzo/bendamustine Yes 01/01/21    
J9039 Injection, blinatumomab Yes 01/01/18    
J9042 Brentuximab vedotin inj Yes 01/01/21    
J9043 Cabazitaxel injection Yes 01/01/21    
J9044 Inj, bortezomib, nos, 0.1 mg Yes 01/01/21    
J9047 Injection, carfilzomib, 1 mg Yes 01/01/21    
J9050 Carmustine injection Yes 01/01/21    
J9055 Injection, cetuximab, 10 mg Yes 01/01/11    
J9057 Inj., copanlisib, 1 mg Yes 01/01/21    
J9061 Inj, amivantamab-vmjw Yes 01/01/22    
J9098 Injection, cytarabine liposome, 10 mg Yes 01/01/11    
J9118 Inj. Calaspargase pegol-mknl Yes 01/01/21    
J9119 Inj., cemiplimab-rwlc, 1 mg Yes 01/01/21    
J9120 Injection, dactinomycin, 0.5 mg Yes 01/01/11    
J9145 Injection, daratumumab 10 mg Yes 01/01/21    
J9153 Inj daunorubicin, cytarabine Yes 01/01/21    
J9160 Injection, denileukin diftitox, 300 micrograms Yes 01/01/11    
J9173 Inj., durvalumab, 10 mg Yes 01/01/21    
J9176 Injection, elotuzumab, 1mg Yes 01/01/21    
J9177 Inj enfort vedo-ejfv 0.25mg Yes 01/01/21    
J9202 Goserelin acetate implant Yes 01/01/18    
J9203 Gemtuzumab ozogamicin 0.1 mg Yes 01/01/21    
J9204 Inj mogamulizumab-kpkc, 1 mg Yes 01/01/21    
J9205 Inj irinotecan liposome 1 mg Yes 01/01/21    
J9207 Injection, ixabepilone, 1 mg Yes 01/01/11    
J9210 Inj., emapalumab-lzsg, 1 mg Yes 01/01/21    
J9219 Leuprolide acetate implant, 65 mg Yes 01/01/11    
J9225 Histrelin implant (vantas), 50 mg Yes 01/01/11    
J9226 Supprelin LA implant Yes 10/01/10    
J9227 Inj. isatuximab-irfc 10 mg Yes 01/01/21    
J9228 Ipilimumab injection Yes 01/01/21    
J9229 Inj inotuzumab ozogam 0.1 mg Yes 01/01/21    
J9245 Injection, melphalan hydrochloride, 50 mg Yes 01/01/11    
J9246 Inj., evomela, 1 mg Yes 01/01/21    
J9261 Nelarabine injection Yes 01/01/21    
J9263 Injection, oxaliplatin, 0.5 mg Yes 01/01/11    
J9264 Injection, paclitaxel protein-bound particles, 1 mg Yes 01/01/11    
J9266 Injection, pegaspargase, per single dose vial Yes 01/01/11    
J9268 Injection, pentostatin, 10 mg Yes 01/01/11    
J9269 Inj. tagraxofusp-erzs 10 mcg Yes 01/01/21    
J9271 Inj pembrolizumab Yes 01/01/18    
J9272 Inj, dostarlimab-gxly, 10 mg Yes 01/01/22    
J9280 Mitomycin injection Yes 07/01/21    
J9285 Inj, olaratumab, 10 mg Yes 01/01/21    
J9295 Injection, necitumumab, 1 mg Yes 01/01/21    
J9299 Injection, nivolumab Yes 01/01/18    
J9301 Obinutuzumab inj Yes 01/01/18    
J9302 Ofatumumab injection Yes 01/01/21    
J9303 Injection, panitumumab, 10 mg Yes 01/01/11    
J9305 Injection, pemetrexed, 10 mg Yes 01/01/11    
J9307 Pralatrexate injection Yes 01/01/18    
J9308 Injection, ramucirumab Yes 01/01/18    
J9309 Inj, polatuzumab vedotin 1mg Yes 01/01/21    
J9310 Injection, rituximab, 100 mg Yes 01/01/11    
J9311 Inj rituximab, hyaluronidase Yes 01/01/21    
J9312 Inj., rituximab, 10 mg Yes 01/01/21    
J9313 Inj., lumoxiti, 0.01 mg Yes 01/01/21    
J9325 Inj talimogene laherparepvec Yes 01/01/21    
J9328 Temozolomide injection Yes 01/01/21    
J9350 Injection, topotecan, 4 mg Yes 01/01/11    
J9352 Injection trabectedin 0.1mg Yes 01/01/21    
J9354 Inj, ado-trastuzumab emt 1mg Yes 01/01/18    
J9355 Injection, trastuzumab, 10 mg Yes 01/01/11    
J9356 Inj. herceptin hylecta, 10mg Yes 01/01/21    
J9357 Valrubicin injection Yes 01/01/21    
J9358 Inj fam-trastu deru-nxki 1mg Yes 01/01/21    
J9371 Inj, vincristine sul lip 1mg Yes 01/01/21    
J9400 Inj, ziv-aflibercept, 1mg Yes 01/01/18    
J9600 Injection, porfimer sodium, 75 mg Yes 01/01/11    
M0075 Cellular therapy No 01/01/22    
M0201 Covid-19 vaccine home admin No 01/01/21    
M0220 Tixagev and cilgav inj No of 1/26/23 01/01/22    
M0221 Tixagev and cilgav inj hm No 01/01/22    
M0222 Bebtelovimab injection Yes 01/01/22    
M0223 Bebtelovimab injection home No 01/01/22    
M0239 Intravenous infusion, bamlanivimab-xxxx, includes infusion and post administration monitoring Yes 01/01/21    
M0240 Casiri and imdev repeat No 07/01/21    
M0241 Casiri and imdev repeat hm No 07/01/21    
M0243 Casirivi and imdevi infusion No 01/01/21    
M0244 Casirivi and imdevi inj hm No 01/01/21    
M0245 Bamlan and etesev infusion No 01/01/21    
M0246 Bamlan and etesev infus home No 01/01/21    
M0247 Sotrovimab infusion Yes 01/01/21    
M0248 Sotrovimab inf, home admin No 01/01/21    
M0249 Adm Tocilizu COVID-19 1st No 01/01/21    
M0250 Adm Tocilizu COVID-19 2nd No 01/01/21    
M0301 Fabric wrapping of aneurysm No 01/01/22    
P9099 Blood component/product noc No 07/01/20    
P9603 One-way allow prorated miles No 01/01/20    
P9604 One-way allow prorated trip No 01/01/20    
Q0091 Obtaining screen pap smear No 01/01/12    
Q0220 Tixagev and cilgav inj No of 1/26/23 01/01/22    
Q0221 Tixagev and cilgav, 600mg No of 1/26/23 01/01/22    
Q0222 Bebtelovimab 175 mg Yes 01/01/22    
Q0239 Injection, bamlanivimab, 700 mg Yes 01/01/21    
Q0240 Casirivi and imdevi 600mg No 07/01/21    
Q0243 Casirivimab and imdevimab No 01/01/21    
Q0244 Casirivi and imdevi 1200 mg No 01/01/21    
Q0245 Bamlanivimab and etesevima No 01/01/21    
Q0247 Sotrovimab Yes 01/01/21    
Q0249 Tocilizumab for COVID-19 No 01/01/21    
Q2017 Teniposide, 50 mg Yes 01/01/21    
Q2043 Provenge Yes 07/01/14    
Q2049 Imported lipodox inj No 01/01/16    
Q2050 Doxorubicin inj 10mg Yes 01/01/18    
Q4074 Iloprost, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, up to 20 micrograms Yes 01/01/11    
Q5108 Injection, fulphila Yes 01/01/21    
Q5111 Injection, udenyca 0.5 mg Yes 01/01/21    
Q5112 Inj ontruzant 10 mg Yes 01/01/21    
Q5113 Inj herzuma 10 mg Yes 01/01/21    
Q5114 Inj ogivri 10 mg Yes 01/01/21    
Q5115 Inj truxima 10 mg Yes 01/01/21    
Q5116 Inj., trazimera, 10 mg Yes 01/01/21    
Q5117 Inj., kanjinti, 10 mg Yes 01/01/21    
Q5118 Inj., zirabev, 10 mg Yes 01/01/22    
Q5119 Inj ruxience, 10 mg Yes 01/01/21    
Q5120 Inj pegfilgrastim-bmez 0.5mg Yes 01/01/21    
S0013 Esketamine, nasal spray Yes 01/01/23    
S0166 Inj olanzapine 2.5mg No 04/01/11    
S0190 Mifepristone, oral, 200 mg Yes 12/01/08    
S0191 Misoprostol, oral, 200 mcg Yes 12/01/08    
S0199 Med abortion inc all ex drug No 01/01/20    
S2070 Cysto laser tx ureteral calc No 01/01/22    
S2079 Lap esophagomyotomy No 01/01/22    
S2080 Laup No 01/01/22    
S2095 Transcath emboliz microspher No 01/01/22    
S2102 Islet cell tissue transplant No 01/01/22    
S2107 Adoptive immunotherapy No 01/01/22    
S2115 Periacetabular osteotomy No 01/01/22    
S2117 Arthroereisis, subtalar No 01/01/22    
S2120 Low density lipoprotein(ldl) No 01/01/22    
S2150 Bmt harv/transpl 28d pkg No 01/01/22    
S2202 Echosclerotherapy No 01/01/20    
S3800 Genetic testing als No 01/01/16    
S3818 BRCA1 gene anal Yes 01/01/10    
S3819 BRCA2 gene anal Yes 01/01/10    
S3820 Comp BRCA1/BRCA2 Yes 01/01/10    
S3822 Sing mutation brst/ovar Yes 01/01/10    
S3823 3 mutation brst/ovar Yes 01/01/10    
S3828 Comp MLH1 gene Yes 01/01/10    
S3829 Comp MLH2 gene Yes 01/01/10    
S3830 Gene test HNPCC comp Yes 01/01/10    
S3831 Gene test HNPCC single Yes 01/01/10    
S3833 Comp APC sequence Yes 01/01/10    
S3834 Sing mutation APC Yes 01/01/10    
S3835 Gene test cystic fibrosis Yes 01/01/10    
S3840 DNA analysis RET-oncogene Yes 01/01/10    
S3841 Gene test retinoblastoma No 01/01/16    
S3842 Gene test Hippel-Lindau Yes 01/01/10    
S3843 DNA analysis factor v Yes 01/01/10    
S3844 DNA analysis deafness Yes 01/01/10    
S3845 Gene test alpha-thalassemia No 01/01/10    
S3846 Gene test beta-thalassemia Yes 01/01/10    
S3847 Gene test Tay-Sachs Yes 01/01/10    
S3848 Gene test Gaucher Yes 01/01/10    
S3849 Gene test Niemann-Pick Yes 01/01/10    
S3850 Gene test sickle cell Yes 01/01/10    
S3851 Gene test canavan Yes 01/01/10    
S3852 DNA analysis APOE alzheimer Yes 01/01/10    
S3853 Gene test myo musclr dyst Yes 01/01/10    
S3854 Gene profile panel breast No 01/01/16    
S3861 Genetic test brugada Yes 01/01/16    
S3865 Comp genet test hyp cardiomy Yes 01/01/16    
S3866 Spec gene test hyp cardiomy Yes 01/01/16    
S3870 Cgh test developmental delay No 01/01/16    
S3890 Fecal dna analysis No 01/01/16    
S4026 Procure donor sperm No 07/01/21    
S4027 Store prev froz embryos No 07/01/21    
S4040 Monit store cryo embryo 30 d No 07/01/21    
S4989 Contracept IUD Yes 12/01/08    
S8940 Hippotherapy per session No 12/01/08    
S9055 Procuren or other growth fac No 01/01/22    
S9075 Smoking cessation treatment No 12/01/08    
S9128 Speech therapy, in the home, No 12/01/08    
S9129 Occupational therapy, in the No 12/01/08    
S9131 PT in the home per diem No 12/01/08    
S9453 Smoking cessation class No 12/01/08    
S9480 Intensive outpatient psychia No 07/01/10 01/01/11  
S9529 Venipuncture home/snf No 01/01/20    
T1040 Comm bh clinic svc per diem No 01/01/17    
T1041 Comm bh clinic svc per month No 01/01/17    
U0002 Covid-19 lab test non-cdc Yes 01/01/20    
U0003 Infectious agent detection Yes 04/01/20    
U0004 2019-nCoV Coronavirus, SARS Yes 04/01/20    
U0005 Infec agen detec ampli probe Yes 01/01/22    
V5014 Hearing aid repair/modifying Yes 04/01/12    
V5362 Speech screening No 04/01/11    
V5364 Dysphagia screening No 04/01/11    

*Procedure codes listed as carve outs should not be billed using APGs. Indication as a carve out does not guarantee alternative payment.
** Procedure codes became obsolete effective 1/1/2017.

Yes = Procedure code is not payable in APGs but is available for billing on ordered ambulatory fee schedule.

No = Procedure code is not reimbursable by Medicaid. Service may be billable under an alternative procedure code.

TBD = At this time Medicaid Policy has not made a final determination regarding these procedures. Once a final determination has been made, they will be adjusted on this list or just added into the general APG logic.