CPT 95905, G0255 - Automated Point-of-Care Nerve Conduction Tests

Coding Code Description CPT

95905 Motor and/or sensory nerve conduction, using preconfigured electrode array(s), amplitude and latency/velocity study, each limb, includes F-wave study when performed, with interpretation and report HCPCS

G0255 Current perception threshold/sensory nerve conduction test (SNCT), per limb

Introduction

A nerve conduction test looks at how well nerves work. The purpose of the test is to see if a nerve is damaged. Two electrodes — patches attached to the skin that can transmit electrical signals — are placed along the path of the nerve being tested. An electrical signal is sent to the first electrode, with the second electrode receiving and recording the signal. The time it takes the electrical signal to travel between the two electrodes indicates how well the signal travels along the nerve. Specialized equipment is needed to do these tests. Newer types of portable equipment have been developed to try to do nerve conduction tests. Portable equipment is not as specialized and doesn’t require special training to use it. Portable equipment for nerve conduction studies is considered unproven. More studies are needed to show if the nerve conduction studies done on portable equipment by non-specialists gives information that is the same as or better information than standard nerve conduction studies. Note: The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a service may be covered.

Policy Coverage

Testing Investigational Automated point-of-care nerve conduction tests Automated point-of-care nerve conduction tests are considered investigational.


Related Information N/A

Evidence Review Description


Portable devices have been developed to provide point-of-care (POC) nerve conductions studies (NCSs). These devices have computational algorithms that can drive stimulus delivery, measure and analyze the response, and report study results. Automated nerve conduction could be used in various settings, including primary care, without the need for specialized training or equipment.


Background Electrodiagnostic Testing

Nerve conduction studies (NCSs) and needle electromyography (EMG), when properly performed by a trained practitioner, are considered the criterion standard of electrodiagnostic testing for the evaluation of focal and generalized disorders of peripheral nerves. However, the need for specialized equipment and personnel may limit the availability of electrodiagnostic testing for some patients.

Carpal Tunnel Syndrome

Carpal tunnel syndrome is a pressure-induced entrapment neuropathy of the median nerve as it passes through the carpal tunnel, resulting in sensorimotor disturbances. This syndrome is defined by its characteristic clinical symptoms, which may include pain, subjective feelings of swelling, and nocturnal paresthesia.

Diagnosis

A variety of simple diagnostic tools are available, and a positive response to conservative management (steroid injection, splints, modification of activity) can confirm the clinical diagnosis.1 Electrodiagnostic studies may also be used to confirm the presence or absence of a median neuropathy at the wrist, assess the severity of the neuropathy, and assess associated diagnoses. Nerve conduction is typically assessed before the surgical release of the carpal tunnel, but the use of EMG in the diagnosis of carpal tunnel syndrome is controversial. One proposed use of automated nerve conduction devices is to assist in the diagnosis of carpal tunnel syndrome.

Lumbosacral Radiculopathy


Electrodiagnostic studies are useful in the evaluation of lumbosacral radiculopathy in the presence of disabling symptoms of radiculopathy or neuromuscular weakness. These tests are most commonly considered in patients with persistent disabling symptoms when neuroimaging findings are inconsistent with clinical presentation. Comparisons of automated point-of-care

(POC) NCSs with EMGs and standardized NCSs have been evaluated as alternative electrodiagnostic tools.

Peripheral Neuropathy


Peripheral neuropathy is relatively common in patients with diabetes, and the diagnosis is often made clinically through the physical examination. Diabetic peripheral neuropathy can lead to morbidity including pain, foot deformity, and foot ulceration.

Diagnosis


Clinical practice guidelines have recommended using simple sensory tools such as the 10-g Semmes-Weinstein monofilament or the 128-Hz vibration tuning fork for diagnosis.2 These simple tests show the presence of neuropathy defined by electrophysiologic criteria with a high level of accuracy. Electrophysiologic testing may be used in research studies and may be required in cases with an atypical presentation. POC nerve conduction testing has been proposed as an alternative to standard electrodiagnostic methods for the diagnosis of peripheral neuropathy and, in particular, for detecting neuropathy in patients with diabetes.

Normative Values

NeuroMetrix (2009) published reference ranges for key nerve conduction parameters in healthy subjects.3 Data analyzed were pooled from 5 studies, including from 92 to 848 healthy subjects with data on the median, ulnar, peroneal, tibial, and sural nerves. Subject age and height were found to affect the parameters. In addition to providing reference ranges for clinicians to use (providing that NCS techniques are consistent with those described in the article), the authors stated that clinicians could use the same method to develop their reference ranges. At this time, the proposed reference ranges have not been validated in a clinical patient population. Due to the lack of uniform standards in nerve conduction testing in the United States, the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM) identified 7 criteria that would identify high-quality NCS articles that would be appropriate for using as referent standards (2016). AANEM identified normative criteria for nerve conduction velocity tests based on a review of high-quality published studies (see Table 1). In March 2017, the American Academy of Neurology affirmed AANEM’s recommendations.5

CPT 21010, 21050, 21116, 21240, 29800, 70330 -70355 - Temporomandibular Joint Disorder

Coding Code Description CPT

20605 Arthrocentesis, aspiration and/or injection; intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa)
21010 Arthrotomy, temporomandibular joint
21050 Condylectomy, temporomandibular joint
21060 Menisectomy, partial/complete, temporomandibular joint (separate procedure)
21073 Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (ie, general or monitored anesthesia care)
21085 Impression and custom preparation; oral surgical splint
21089 Unlisted maxillofacial prosthetic procedure
21116 Injection procedure for temporomandibular joint arthrography
21240 Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft)
21242 Arthroplasty, temporomandibular joint, with allograft
21243 Arthroplasty, temporomandibular joint, with prosthetic joint replacement
21480 Closed treatment of temporomandibular dislocation; initial or subsequent
21485 Closed treatment of temporomandibular dislocation; complicated (eg, recurrent requiring intermaxillary fixation or splinting), initial or subsequent
21490 Open treatment of temporomandibular dislocation
29800 Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure)
29804 Arthroscopy, temporomandibular joint, surgical
70328 Radiologic exam, temporomandibular joint, open and closed mouth; unilateral
70330 Radiologic examination, temporomandibular joint, open and closed mouth; bilateral
70332 Temporomandibular joint arthrography, radiological supervision and interpretation
70350 Cephalogram, orthodontic
70355 Orthopantogram (eg, panoramic x-ray)

HCPCS

J7321 Hyaluronan or derivative, Hyalgan or Supartz, 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, for intra-articular injection, 1 mg
J7326 Hyaluronan or derivative, Gel-One, for intra-articular injection, per dose
S3900 Surface electromyography (EMG) CDT
D7880 Occlusal orthotic device
D7881 Occlusal orthotic device adjustment
D7899 Unspecified TMD therapy, by report
D7999 Unspecified oral surgery procedure
D9940 Occlusal guard

Introduction

The temporomandibular joint (TMJ) is the joint where the jawbone connects to the skull. There is one joint on each side of the jaw. The areas of the bones forming the joint are covered with cartilage and separated by a small disk. This disk helps keep joint movement smooth. Sometimes the disc erodes or moves out of its proper position. Arthritis may develop in the joint and damage the cartilage, or an injury can damage the joint. Regardless of the cause, TMJ disorders (TMJD) can result in pain and affect the function of the joint and the muscles that control jaw movement. TMJDs may go away without treatment, or pain relievers can be used to alleviate symptoms. This policy describes the services that the health plan covers (considers medically necessary) to diagnose and treat TMJ symptoms and disorders. On some plans, services to treat TMJ problems are limited to a specific benefit which may have a dollar limit.



Policy Coverage Criteria

Treatment Medical Necessity


Diagnostic procedures The following diagnostic procedures may be considered medically necessary in the diagnosis of temporomandibular joint (TMJ) disorder:

* Diagnostic x-ray, tomograms, and arthrograms
* Computed tomography (CT) scan or magnetic resonance imaging (MRI) (in general, CT scans and MRIs are reserved for presurgical evaluations)
* Cephalograms (x-rays of jaws and skull)
* Pantograms (x-rays of maxilla and mandible)

Note: Cephalograms and pantograms should be reviewed on an individual basis.

Surgical treatments The following surgical treatments may be considered medically necessary in the treatment of TMJ disorder:

* Arthrocentesis
* Manipulation for reduction of fracture or dislocation of the TMJ
* Arthroscopic surgery in patients with objectively demonstrated (by physical examination or imaging) internal derangements (displaced discs) or degenerative joint disease who have failed conservative treatment
* Open surgical procedures (when TMJ disorder results from congenital anomalies, trauma, or disease in patients who have failed conservative treatment) including, but not limited to:
o Arthroplasties
o Condylectomies
o Meniscus or disc plication
o Disc removal

Nonsurgical treatments The following nonsurgical treatments may be considered medically necessary in the treatment of TMJ disorder:

* Intraoral removable prosthetic devices/appliances (encompassing fabrication, insertion, adjustment)
* Pharmacologic treatment (eg, anti-inflammatory, muscle relaxing, analgesic medications)


Diagnostic procedures The following diagnostic procedures are considered investigational in the diagnosis of TMJ disorder:

* Arthroscopy of the TMJ for purely diagnostic purposes
* Computerized mandibular scan (this measures and records muscle activity related to movement and positioning of the mandible and is intended to detect deviations in occlusion and muscle spasms related to TMJD)

* Electromyography (EMG), including surface EMG
* Joint vibration analysis
* Kinesiography
* Muscle testing
* Neuromuscular junction testing
* Range-of-motion measurements
* Somatosensory testing
* Standard dental radiographic procedures
* Thermography
* Transcranial or lateral skull x-rays; intraoral tracing or gnathic arch tracing (intended to demonstrate deviations in the positioning of the jaws that are associated with TMJD)
* Ultrasound imaging/sonogram

Nonsurgical treatments The following nonsurgical treatments are considered investigational in the treatment of TMJ disorder:
* Biofeedback
* Botulinum toxin
* Dental restorations/prostheses
* Devices promoted to maintain joint range of motion and to develop muscles involved in jaw function
* Electrogalvanic stimulation
* Hyaluronic acid
* Iontophoresis
* Orthodontic services
* Percutaneous electrical nerve stimulation (PENS)
* Transcutaneous electrical nerve stimulation (TENS)
* Ultrasound
.



Description

Temporomandibular joint disorder (TMJD) refers to a group of disorders characterized by pain in the temporomandibular joint and surrounding tissues. Initial conservative therapy is generally recommended; there are also a variety of nonsurgical and surgical treatment possibilities for patients whose symptoms persist.

Background


Temporomandibular joint disorder (TMJD; also known as temporomandibular joint syndrome) refers to a cluster of problems associated with the temporomandibular joint (TMJ) and musculoskeletal structures. The etiology of TMJD remains unclear and is believed to be multifactorial. TMJD are often divided into two main categories: articular disorders (eg, ankylosis, congenital or developmental disorders, disc derangement disorders, fractures, inflammatory disorders, osteoarthritis, joint dislocation) and masticatory muscle disorders (eg, myofascial pain, myofibrotic contracture, myospasm, neoplasia). Diagnosis

In the clinical setting, TMJD is often a diagnosis of exclusion and involves physical examination, patient interview, and review of dental records. Diagnostic testing and radiologic imaging is generally only recommended for patients with severe and chronic symptoms. Diagnostic criteria for TMJD have been developed and validated for use in both clinical and research settings.1-3 Symptoms attributed to TMJD are varied and include, but are not limited to, clicking sounds in the jaw; headaches; closing or locking of the jaw due to muscle spasms (trismus) or displaced disc; pain in the ears, neck, arms, and spine; tinnitus; and bruxism (clenching or grinding of the teeth).

Treatment

For many patients, symptoms of TMJD are short-term and self-limiting. Conservative treatments, such as eating soft foods, rest, heat, ice, and avoiding extreme jaw movements, and antiinflammatory medication, are recommended before consideration of more invasive and/or permanent therapies, such as surgery.


The most recent literature review was through December 20, 2016. Recent literature searches have concentrated on identifying systematic reviews and meta-analyses. For treatment of temporomandibular joint disorders (TMJD), the focus has been on studies that compared novel treatments with conservative interventions and/or placebo controls (rather than no-treatment control groups) and that reported pain reduction and/or functional outcomes (eg, jaw movement).

Botulinum Toxin A 2015 systematic review by Chen et al evaluated the literature on botulinum toxin (Botox) for treatment of temporomandibular joint disorders.36 Eligibility included RCTs comparing any dose or type of botulinum toxin with any alternative intervention or placebo. Five RCTs met the inclusion criteria; three were parallel group studies, and two were crossover studies. Study sizes tended to be small; all but 1 study included 30 or less participants. Three of the 5 studies were judged to be at high risk of bias. All studies administered a single injection of botulinum toxin and followed patients up at least 1 month later. Four studies used a placebo (normal saline) control group and the fifth used botulinum toxin to fascial manipulation.

The primary outcome was a validated pain scale. Data were not pooled due to heterogeneity among trials. In a qualitative review of the studies, only 2 of the 5 trials found a significant short-term (1-to-2 months) benefit of botulinum toxin compared with control on pain reduction. Summary of Evidence

For individuals who have suspected temporomandibular joint disorder (TMJD) who receive ultrasound, surface electromyography, or joint vibration analysis, the evidence includes systematic reviews of diagnostic test studies. Relevant outcomes are test accuracy, test validity, and other performance measures. None of the systematic reviews found that these diagnostic techniques accurately identify patients with TMJD and many of the included studies had methodologic limitations. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have a confirmed diagnosis of TMJD who receive intraoral devices or appliances or pharmacologic treatment, the evidence includes randomized controlled trials (RCTs) and systematic reviews of the RCTs. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. A systematic review of intraoral appliances (44 studies) and meta-analyses of subsets of these studies found a significant benefit of intraoral appliances compared with control interventions. Other systematic reviews found a significant benefit of several pharmacologic treatments (eg, analgesics, muscle relaxants, and anti-inflammatory medications [vs placebo]). The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals who have a confirmed diagnosis of TMJD who receive acupuncture, biofeedback, transcutaneous electrical nerve stimulation, orthodontic services, or hyaluronic acid, the evidence includes RCTs, systematic reviews of these RCTs, and observational studies. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. The systematic reviews did not find that these technologies reduced pain or improved functional outcomes significantly more than control treatments. Moreover, many individual studies were small and/or had methodologic limitations. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have a confirmed diagnosis of TMJD, who receive arthrocentesis or arthroscopy, the evidence includes RCTs and systematic reviews of the RCTs. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. Only 1 review, which included 3 RCTs, compared arthrocentesis or arthroscopy with nonsurgical interventions for TMJD. Pooled analyses of the RCTs found that arthrocentesis and arthroscopy resulted in superior pain reduction than control interventions. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome. A systematic review of RCTs found insufficient evidence that botulinum toxin improves the net health outcome in patients with temporomandibular joint disorders. Studies tended to be small, have a high risk of bias, and only 2 of 5 RCTs found that botulinum toxin reduced pain more than a comparator.

CPT code list for infertility - 54500, g0027, s3655, 58322

Introduction

Infertility is a problem or problems with the reproductive system that affects the ability to  conceive.  Different types of  reproductive problems affect men and women, but the end result is  the inability to  conceive or complete a pregnancy.  There are many reasons for infertility and  many different types of treatments. Even though an infertility treatment exists , it does not mean  it is covered ; the  member’s contract determines this . (Services to diagnose infertility  are covered  as a medical benefit.) This benefit coverage guideline lists types  of  services that may be  allowed if a member’s contract  covers infertility  treatments.

Note:
The Introduction section is for your general knowledge and is not to be  taken as policy coverage criteria . The  rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for  providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider  also can be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a  service may be covered

Coding Code Description 

Diagnostic  Services to Evaluate Potential Infertility
CPT

54500 Biopsy of testis, needle (separate procedure)
54505 Biopsy of testis, incisional (separate procedure)
54800 Biopsy of epididymis, needle
55200 Vasotomy, cannulization with or without incision of vas, unilateral or bilateral (separate  procedure)
55300 Vasotomy for vasograms, seminal vesiculograms, or epididymograms, unilateral or  bilateral
55550 Laparoscopy, surgical, with ligation of spermatic veins for varicocele
8340 Catheterization and introduction of saline or contrast material for saline infusion  sonohysterography (SIS) or hysterosalpingography
58345 Transcervical introduction of fallopian tube catheter for diagnosis and/or re-establishing patency (any method), with or without hysterosalpingography
58350 Chromotubation of oviduct, including materials
58540 Hysteroplasty, repair of uterine anomaly (Strassman type)
58560 Hysteroscopy, surgical; with division or resection of intrauterine septum (any method)
58700 Salpingectomy, complete or partial, unilateral or bilateral (separate procedure)
58740 Lysis of adhesions (salpingolysis, ovariolysis)
58752 Tubouterine implantation
58770 Salpingostomy (salpingoneostomy)
58920 Wedge resection or bisection of ovary, unilateral or bilateral
74740 Hysterosalpingography, radiological supervision and interpretation
76831 Saline infusion sonohysterography (SIS), including  color flow Doppler, when performed
83001 Gonadotropin; follicle stimulating hormone (FSH)
83002 Gonadotropin; luteinizing hormone (LH)
89300 Semen analysis; presence and/or motility of sperm including Huhner test (post coital)
89310 Semen analysis; motility and count (not including Huhner test)
89320 Semen analysis; volume, count, motility, and differential
89321 Semen analysis; sperm presence and motility of sperm, if performed
89322 Semen analysis; volume, count, motility, and  differential using strict morphologic  criteria (eg, Kruger)
89330 Sperm evaluation; cervical mucus penetration test, with or without spinnbarkeit test
89331 Sperm evaluation, for retrograde ejaculation, urine (sperm concentration, motility, and  morphology, as indicated)

HCPCS

G0027 Semen analysis; presence and/or motility of sperm excluding Huhner
S3655 Antisperm antibodies test (immunobead)

Assisted Fertilization Services

If there is a difference between the information listed in the tables below  and the member’s  contract, the member’s contract prevails.

Ovulation Induction HCPCS

J0725 Injection, chorionic gonadotropin, per 1,000 USP units
J3355 Injection, urofollitropin, 75 IU
Q0115 Postcoital direct, qualitative examinations of vaginal or cervical mucous
S0122 Injection, menotropins, 75 IU
S0126 Injection, follitropin alfa, 75 IU
S0128 Injection, follitropin beta, 75 IU
S0132 Injection, ganirelix acetate, 250 mcg
S4022 Assisted oocyte  fertilization, case rate
S4042 Management of ovulation induction (interpretation of diagnostic tests and studies,  non  face - to - face medical management of the patient), per cycle

Intrauterine Insemination
CPT

58321 Artificial insemination; intra - cervical
58322 Artificial insemination; intra - uterine
58323 Sperm washing for artificial insemination
89260 Sperm isolation; simple prep (eg, sperm wash and swim - up) for insemination or  diagnosis with semen analysis
89261 Sperm isolation; complex prep (eg,  Percoll gradient, albumin gradient) for  insemination or diagnosis with semen analysis
89268 Insemination of oocyte

HCPCS
S4035 Stimulated intrauterine insemination (IUI), case rate
S3655 Antisperm antibodies test (immunobead)

Advanced  Reproductive/Fertilization Services
CPT 0357T Cryopreservation; immature oocyte(s)
58970 Follicle puncture for oocyte retrieval, any method
58974 Embryo transfer, intrauterine
76948 Ultrasonic guidance for aspiration of ova, imaging supervision and  interpretation
89250 Culture of oocyte(s)/embryo(s), less than 4 days
89251 Culture of oocyte(s)/embryo(s), less than 4 days; with co - culture of oocyte(s)/embryos
89253 Assisted embryo hatching, microtechniques (any method)
89254 Oocyte identification  from follicular fluid
89255 Preparation of embryo for transfer (any method)
89257 Sperm identification from aspiration (other than seminal fluid)
89258 Cryopreservation; embryo(s)
89259 Cryopreservation; sperm
89264 Sperm identification from testis  tissue, fresh or cryopreserved
89272 Extended culture of oocyte(s)/embryo(s), 4 - 7 days
89325 Sperm antibodies
89329 Sperm evaluation; hamster penetration test
89335 Cryopreservation, reproductive tissue, testicular
89337 Cryopreservation, mature  oocyte(s)
89342 Storage (per year); embryo(s)
89343 Storage (per year); sperm/semen
89344 Storage (per year); reproductive tissue, testicular/ovarian
89346 Storage (per year); oocyte(s)
89352 Thawing of cryopreserved; embryo(s)
89353 Thawing of  cryopreserved; sperm/semen, each aliquot
89354 Thawing of cryopreserved; reproductive tissue, testicular/ovarian
89356 Thawing of cryopreserved; oocytes, each aliquot

HCPCS
S4011 In vitro fertilization; including but not limited to identification and  incubation of  mature oocytes, fertilization with sperm, incubation of embryo(s), and subsequent  visualization for determination of development
S4015 Complete in vitro fertilization cycle, not otherwise specified, case rate
S4016 Frozen in vitro  fertilization cycle, case rate
S4017 Incomplete cycle, treatment cancelled prior to stimulation, case rate
S4018 Frozen embryo transfer procedure cancelled before transfer, case rate
S4020 In vitro fertilization procedure cancelled before aspiration, case rate
S4021 In vitro fertilization procedure cancelled after aspiration, case rate
S4023 Donor egg cycle, incomplete, case rate
S4025 Donor services for in vitro fertilization (sperm or embryo), case rate
S4026 Procurement of donor sperm from sperm  bank
S4027 Storage of previously frozen embryos
S4028 Microsurgical epididymal sperm aspiration (MESA)
S4030 Sperm procurement and cryopreservation services; initial visit
S4031 Sperm procurement and cryopreservation services; subsequent visit
S4040 Monitoring and storage of cryopreserved embryos, per 30 days
0058T Cryopreservation; reproductive tissue, ovarian
0357T Cryopreservation; immature oocyte(s)

Zygote Intra - Fallopian Transfer (ZIFT)
CPT

58976 Gamete, zygote, or embryo intrafallopian transfer, any method

HCPCS
S4014 Complete cycle, zygote intrafallopian transfer (ZIFT), case rate Gamete Intra - Fallopian Transfer (GIFT) CPT

S4013 Complete cycle, gamete intrafallopian transfer (GIFT), case rate Cryopreserved Embryo Transfers

HCPCS
S4037 Cryopreserved embryo transfer, case rate
S4018 Frozen embryo transfer procedure cancelled before transfer Intracytoplasmic Sperm Injection (ICSI); or Ovum Microsurgery

CPT
89280 Assisted oocyte fertilization, microtechnique; less than or equal to 10 oocytes
89281 Assisted oocyte fertilization, microtechnique; greater than 10 oocytes
55870 Electroejaculation

Unlisted Code
CPT

89398 Unlisted reproductive medicine lab procedure

Sterilization Reversal Services
If there is a difference between the information listed in the tables below and the member’s  contract, the member’s contract prevails.

55400 Vasovasostomy, vasovasorrhaphy
58679 Unlisted laparoscopy procedure, oviduct, ovary
58750 Tubotubal anastomosis
58760 Fimbrioplasty
58672 Laparoscopy, surgical; with fimbrioplasty
58673 Laparoscopy, surgical; with salpingostomy (salpingoneostomy)
69990 Microsurgical techniques, requiring use of operating microscope (List separately in  addition to code for primary procedure)

Note :
CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). HCPCS  codes, descriptions and materials are copyrighted by Centers for Medicare Services (CMS)/


Definition of Terms

Impaired fecundity:

A woman is physically able to have a child but is unable to conceive a pregnancy or carry a pregnancy to live birth.

Infertility:

“Not being able to get pregnant (conceive) after one year of unprotected sex.”

Infertility is “ ...  the result of a disease (an interruption, cessation, or disorder of body functions,  systems, or organs) of the male or female reproductive tract which prevents the conception of a child or the ability to carry a pregnancy to delivery.

The rates of impaired fecundity and infertility in the United States in 2011 - 2015 of men and  women aged 15 – 44, reported by the National  Center for Health Statistics :
* Infertility rate among married women:  6.7 %
* Impaired fecundity among all women:  12.1 %

Description

A variety of techniques are available to establish a viable pregnancy for couples who have been  diagnosed with infertility and for whom assisted insemination has been unsuccessful.

Infertility

Infertility can be due either to female factors (ie , pelvic adhesions, ovarian dysfunction,  endometriosis,  or  prior tubal ligation), male factors (ie
, abnormalities in sperm production,  function,  or transport , or prior vasectomy), a combination of both male and female factors, or  other  unknown causes.


Treatment

Various reproducti ve techniques are available to establish a viable pregnancy; different  techniques are used depending on the reason for infertility.

Assisted reproductive technologies  (ARTs), as defined by the Centers for Disease Control and Prevention (CDC) and other  organizations, refers to fertility treatments in which both the eggs and sperm are handled. Not  included in ART is assisted insemination (artificial insemination) using sperm from either a  woman’s partner or a sperm donor. In most instances, ART will involve in vitro fertilization (IVF),  a procedure in which oocytes harvested from the female are inseminated in vitro with sperm  harvested from the male. Following the fertilization procedure, the zygote is cultured and  ultimately transferred back into the female’s uterus or fallopian tubes. In some instances, the  oocyte and sperm are collected, but no in vitro fertilization takes place, and the gametes are  reintroduced into the fallopian tubes. Examples of ARTs include, but are not limited to, gamete  intrafallopian transfer (GIFT), transuterine fallopian transfer (TUFT), natural oocyte retrieval with  intravaginal fertilization (NORIF), pronuclear state tubal transfer (PROST), tubal embryo transfer
(TET), zygote intrafallopian transfer (ZIFT), gamete and embryo cryopreservation, oocyte and embryo donation, and gestational surrogacy.

The various components of ART and implantation into the uterus can be broadly subdivided into oocyte harvesting procedures, which are performed on the female partner; sperm collection  procedures, which are performed on the male partner ; and the in vitro component,  ( ie, the  laboratory procedures ) , which are performed on the collected oocyte and sperm. The final step  is the implantation procedure.

Pathology billing - Medicare payment guidelines


Payment for Pathology Services


A.Payment for Professional Component (PC) Services

Payment may be made under the physician fee schedule for the professional component of physician laboratory or physician pathology services furnished to hospital inpatients or outpatients by hospital physicians or by independent laboratories, if they qualify as the
re-assignee for the physician service.

B.Payment for Technical Component (TC) Services

1.General Rule


Payment is not made under the physician fee schedule for TC services furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital inpatient and outpatient settings. Payment is made under the physician fee schedule for TC services furnished in institutional settings where the TC service is not bundled into the facility payment, e.g., an ambulatory surgery center (ASC).

Payment may be made under the physician fee schedule for the TC of physician pathology services furnished by an independent laboratory, or a hospital if it is acting as an independent laboratory, to non-hospital patients. The physician fee schedule identifies physician laboratory or physician pathology services that have a TC service.

2.TC Services Furnished by Independent Laboratories to Hospital Inpatients and Outpatients


*For services furnished on or after July 1, 2012, an independent laboratory may not bill the Medicare contractor (and the Medicare contractor may not pay) for the TC of a physician pathology service furnished to a hospital inpatient or outpatient.

*For services furnished prior to July 1, 2012, payment may be made under the fee schedule, as noted below, for the (TC) of pathology services furnished by an independent laboratory to hospital inpatients or outpatients.

CMS published a final regulation in 1999 that would no longer allow independent laboratories to bill under the physician fee schedule for the TC of physician pathology services. The implementation of this regulation was delayed by Section 542 of the Benefits and Improvement and Protection Act of 2000 (BIPA). Section 542 allows the Medicare carrier to continue to pay for the TC of physician pathology services when an independent laboratory furnishes this service to an inpatient or outpatient of a covered hospital. This provision is applicable to TC services furnished January 1, 2001 through June 30, 2012.

For this provision, a covered hospital is a hospital that had an arrangement with an independent laboratory that was in effect as of July 22, 1999, under which a laboratory furnished the TC of physician pathology services to fee-for-service Medicare beneficiaries who were hospital inpatients or outpatients, and submitted claims for payment for the TC to a carrier. The TC could have been submitted separately or combined with the professional component and reported as a combined service.

The term, fee-for-service Medicare beneficiary, means an individual who:

*Is entitled to benefits under Part A or enrolled under Part B of title XVIII or both; and

*Is not enrolled in any of the following: A Medicare + Choice plan under Part C of such title; a plan offered by an eligible organization under §1876 of the Social Security Act; a program of all-inclusive care for the elderly under
§1894; or a social health maintenance organization demonstration project established under Section 4108 of the Omnibus Budget Reconciliation Act of 1987.

In implementing Section 542, the contractors should consider as independent laboratories those entities that it has previously recognized as independent laboratories.

An independent laboratory that has acquired another independent laboratory that had an arrangement of July 22, 1999, with a covered hospital, can bill the TC of physician pathology services for that hospital’s inpatients and outpatients under the physician fee schedule.

An independent laboratory that furnishes the TC of physician pathology services to inpatients or outpatients of a hospital that is not a covered hospital may not bill the carrier for the TC of physician pathology services during the time §542 is in effect.

If the arrangement between the independent laboratory and the covered hospital limited the provision of TC physician pathology services to certain situations or at particular times, then the independent laboratory can bill the carrier only for these limited services.

The contractor shall require independent laboratories that had an arrangement, on or prior to July 22, 1999 with a covered hospital, to bill for the technical component of physician pathology services to provide a copy of this agreement, or other documentation

substantiating that an arrangement was in effect between the hospital and the independent laboratory as of this date. The independent laboratory must submit this documentation for each covered hospital that the independent laboratory services.

C.Physician Laboratory and Pathology Services

Physician laboratory and pathology services are limited to:

*Surgical pathology services;

*Specific cytopathology, hematology and blood banking services that have been identified to require performance by a physician and are listed below;

*Clinical consultation services that meet the requirements in subsection 3 below; and

*Clinical laboratory interpretation services that meet the requirements and which are specifically listed in subsection 4 below.

1.Surgical Pathology Services

Surgical pathology services include the gross and microscopic examination of organ tissue performed by a physician, except for autopsies, which are not covered by Medicare.

Depending upon circumstances and the billing entity, the contractors may pay professional component, technical component or both.

2.Specific Hematology, Cytopathology and Blood Banking Services

Cytopathology services include the examination of cells from fluids, washings, brushings or smears, but generally excluding hematology. Examining cervical and vaginal smears are the most common service in cytopathology. Cervical and vaginal smears do not require interpretation by a physician unless the results are or appear to be abnormal. In such cases, a physician personally conducts a separate microscopic evaluation to determine the nature of an abnormality. This microscopic evaluation ordinarily does require performance by a physician. When medically necessary and when furnished by a physician, it is paid under the fee schedule.

For services furnished prior to January 1, 1999, contractors pay separately under the physician fee schedule for the interpretation of an abnormal pap smear furnished to a hospital inpatient by a physician. They must pay under the clinical laboratory fee schedule for pap smears furnished in all other situations. This policy also applies to screening pap smears requiring a physician interpretation. For services furnished on or after January 1, 1999, contractors allow separate payment for a physician’s interpretation of a pap smear to any patient (i.e., hospital or non-hospital) as long as: (1) the

laboratory’s screening personnel suspect an abnormality; and (2) the physician reviews and interprets the pap smear.

This policy also applies to screening pap smears requiring a physician interpretation and described in the National Coverage Determination Manual and Chapter 18. These services are reported under codes P3000 or P3001.

Physician hematology services include microscopic evaluation of bone marrow aspirations and biopsies. It also includes those limited number of peripheral blood smears which need to be referred to a physician to evaluate the nature of an apparent abnormality identified by the technologist. These codes include 85060, 38220, 85097, and 38221.

Contractors pay the PC for the interpretation of an abnormal blood smear (code 85060) furnished to a hospital inpatient by a hospital physician or an independent laboratory. For other hematology codes, payment may be made for the PC component if the service is furnished to a patient by a hospital physician or independent laboratory. In addition, payment may be made for these services furnished to patients by an independent laboratory.

Blood banking services of hematologists and pathologists are paid under the physician fee schedule when analyses are performed on donor and/or patient blood to determine compatible donor units for transfusion where cross matching is difficult or where contamination with transmissible disease of donor is suspected.

The blood banking codes are 86077, 86078, and 86079 and represent professional component only services.

3.Clinical Consultation Services

Clinical consultations are paid under the physician fee schedule only if they:

a.Are requested by the patient’s attending physician;

b.Relate to a test result that lies outside the clinically significant normal or expected range in view of the condition of the patient;

c.Result in a written narrative report included in the patient’s medical record; and

d.Require the exercise of medical judgment by the consultant physician.

Clinical consultations are professional component services only, i.e., there is no TC service. The clinical consultation codes are 80500 and 80502.

Routine conversations held between a laboratory director and an attending physician about test orders or results do not qualify as consultations unless all four requirements are met. Laboratory personnel, including the director, may from time to time contact attending physicians to report test results or to suggest additional testing or be contacted by attending physicians on similar matters. These contacts do not constitute clinical consultations. However, if in the course of such a contact, the attending physician requests a consultation from the pathologist, and if that consultation meets the other criteria and is properly documented, it is paid under the fee schedule.

EXAMPLE: A pathologist telephones a surgeon about a patient’s suitability for surgery based on the results of clinical laboratory test results. During the course of their conversation, the surgeon asks the pathologist whether, based on test results, patient history and medical records, the patient is a candidate for surgery. The surgeon’s request requires the pathologist to render a medical judgment and provide a consultation. The pathologist follows up his/her oral advice with a written report and the surgeon notes in the patient’s medical record that he/she requested a consultation. This consultation is paid under the fee schedule.

In any case, if the information could ordinarily be furnished by a nonphysician laboratory specialist, the service of the physician is not a consultation payable under the fee schedule.

See the Program Integrity Manual for guidelines for related data analysis to identify inappropriate patterns of billing for consultations.

4.Clinical Laboratory Interpretation Services

Only clinical laboratory interpretation services, which meet the criteria in subsections C.3.a, c, and d, are billable under the physician fee schedule. These codes have a PC/TC indicator of “6” on the Medicare Physician Fee Schedule database. These services are reported under the clinical laboratory code with modifier 26. These services can be paid under the physician fee schedule if they are furnished to a patient by a hospital pathologist or an independent laboratory. Note that a hospital’s standing order policy can be used as a substitute for the individual request by the patient’s attending physician.

Contractors are not allowed to revise CMS’s list to accommodate local medical practice. The CMS periodically reviews this list and adds or deletes clinical laboratory codes as warranted.

D.Global Billing


Billing globally for services that are split into separate PC and TC services is only possible when the PC and TC are furnished by the same physician or supplier entity. For example, where the PC and the TC of a diagnostic service are provided in the same service location, this is reflected as the address entered into Item 32 on CMS Form 1500, which provides the ZIP Code to pay the right locality/GPCI. In this case, the physician/entity may bill globally. However, if the PC and the TC are each provided in different service locations (enrolled practice locations), the PC and the TC must be separately billed.


Merely applying the same place of service (POS) code to the PC and the TC does not permit global billing for any diagnostic procedure.

CPT 99490, 99487, 99489 - Chronic Care Management Services - Medicare guidelines

Chronic Care Management Services
 - CCM

CPT 99490 Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements:

● Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient

● Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline

● Comprehensive care plan established, implemented, revised, or monitored


Complex CCM

CPT 99487 Complex chronic care management services, with the following required elements:

● Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient

● Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline

● Establishment or substantial revision of a comprehensive care plan

● Moderate or high complexity medical decision making

● 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month

CPT 99489 Each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure)

Complex CCM services of less than 60 minutes in duration, in a calendar month, are not reported separately.

Report 99489 in conjunction with 99487. Do not report 99489 for care management services of less than 30 minutes additional to the first 60 minutes of complex CCM services during a calendar month. CCM (sometimes referred to as “non-complex” CCM) and complex CCM services share a common set of service elements (summarized in Table 1). They differ in the amount of clinical staff service time provided; the involvement and work of the billing practitioner; and the extent of care planning performed.


Only one practitioner may be paid for CCM services for a given calendar month. This practitioner must only report either complex or non-complex CCM for a given patient for the month (not both).

Practitioner Eligibility

Physicians and the following non-physician practitioners may bill CCM services:

● Certified Nurse Midwives

● Clinical Nurse Specialists

● Nurse Practitioners

● Physician Assistants

NOTE: CCM may be billed most frequently by primary care practitioners, although in certain circumstances specialty practitioners may provide and bill for CCM. The CCM service is not within the scope of practice of limited license physicians and practitioners such as clinical psychologists, podiatrists, or dentists, although practitioners may refer or consult with such physicians and practitioners to coordinate and manage care.

CCM services that are not provided personally by the billing practitioner are provided by clinical staff under the direction of the billing practitioner on an “incident to” basis (as an integral part of services provided by the billing practitioner), subject to applicable State law, licensure, and scope of practice. The clinical staff are either employees or working under contract to the billing practitioner whom Medicare directly pays for CCM. Time spent directly by the billing practitioner or clinical staff counts toward the threshold clinical staff time required to be spent during a given month in order to bill CCM services. Non-clinical staff time cannot be counted toward the threshold.

Supervision

The CCM codes (CPT 99487, 99489, and 99490) are assigned general supervision under the Medicare PFS. General supervision means when the service is not personally performed by the billing practitioner, it is performed under his or her overall direction and control although his or her physical presence is not required. Patient Eligibility Patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline are eligible for CCM services.

● Billing practitioners may consider identifying patients who require CCM services using criteria suggested in CPT guidance (such as number of illnesses, number of medications or repeat admissions or emergency department visits) or the profile of typical patients in the CPT prefatory language.

● There is a need to reduce geographic and racial/ethnic disparities in health through provision of CCM services. Table 2 provides a number of resources for identifying and engaging subpopulations to help reduce these disparities.

The billing practitioner cannot report both complex and regular (non-complex) CCM for a given patient for a given calendar month. In other words, a given patient receives either complex or non-complex CCM during a given service period, not both.

Examples of chronic conditions include, but are not limited to, the following:

● Alzheimer’s disease and related dementia
● Arthritis (osteoarthritis and rheumatoid)
● Asthma
● Atrial fibrillation
● Autism spectrum disorders
● Cancer
● Cardiovascular Disease
● Chronic Obstructive Pulmonary Disease
● Depression
● Diabetes
● Hypertension
● Infectious diseases such as HIV/AIDS


Initiating Visit

For new patients or patients not seen within one year prior to the commencement of CCM, Medicare requires initiation of CCM services during a face-to-face visit with the billing practitioner (an Annual Wellness Visit [AWV] or Initial Preventive Physical Exam [IPPE], or other face-to-face visit with the billing practitioner). This initiating visit is not part of the CCM service and is separately billed.

Practitioners who furnish a CCM initiating visit and personally perform extensive assessment and CCM care planning outside of the usual effort described by the initiating visit code may also bill HCPCS code G0506 (Comprehensive assessment of and care planning by the physician or other qualified health care professional for patients requiring chronic care management services [billed separately from monthly care management services] [Add-on code, list separately in addition to primary service]). G0506 is reportable once per CCM billing practitioner, in conjunction with CCM initiation.

Patient Consent

Obtaining advance consent for CCM services ensures the patient is engaged and aware of applicable cost sharing. It may also help prevent duplicative practitioner billing. A practitioner must obtain patient consent before furnishing or billing CCM. Consent may be verbal or written but must be documented in the medical
record, and includes informing them about:

● The availability of CCM services and applicable cost-sharing

● That only one practitioner can furnish and be paid for CCM services during a calendar month

● The right to stop CCM services at any time (effective at the end of the calendar month)


Informed patient consent need only be obtained once prior to furnishing CCM, or if the patient chooses to change the practitioner who will furnish and bill CCM.
CCM Service Elements - Highlights The CCM service is extensive, including structured recording of patient health information, maintaining a comprehensive electronic care plan, managing transitions of care and other care management services, and coordinating and sharing patient health information timely within and outside the practice.

Table 1 summarizes the CCM service elements, which apply to both complex and non-complex CCM unless otherwise specified. CCM services are typically provided outside of face-to-face patient visits, and focus on characteristics of advanced primary care such as a continuous relationship with a designated member of the care team; patient support for chronic diseases to achieve health goals; 24/7 patient access to care and health information; receipt of preventive care; patient and caregiver engagement; and timely sharing and use of health information.


Structured Recording of Patient Health Information

● Record the patient’s demographics, problems, medications, and medication allergies using certified Electronic Health Record (EHR) technology. This means a version of certified EHR that is acceptable under the EHR Incentive Programs as of December 31st of the calendar year preceding each Medicare PFS payment year. For more information, visit https://www.cms.gov/Regulations-and-Guidance/Legislation/ EHRIncentivePrograms.

Comprehensive Care Plan

● A person-centered, electronic care plan based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment, and an inventory of resources (a comprehensive plan of care for all health issues, with particular focus on the chronic conditions being managed)

● Provide the patient and/or caregiver with a copy of the care plan

● Ensure the electronic care plan is available and shared timely within and outside the billing practice to individuals involved in the patient’s care

● Care planning tools and resources are publicly available from a number of organizations (see Resources in Table 2)


Comprehensive Care Plan

A comprehensive care plan for all health issues typically includes, but is not limited to, the following elements:
● Problem list
● Expected outcome and prognosis
● Measurable treatment goals
● Symptom management
● Planned interventions and identification of the individuals responsible for each intervention
● Medication management
● Community/social services ordered
● A description of how services of agencies and specialists outside the practice will be directed/coordinated
● Schedule for periodic review and, when applicable, revision of the care plan



Access to Care & Care Continuity

● Provide 24-hour-a-day, 7-day-a-week (24/7) access to physicians or other qualified health care professionals or clinical staff, including providing patients (and caregivers as appropriate) with a means to make contact with health care professionals in the practice to address urgent needs regardless of the time of day or day of week

● Ensure continuity of care with a designated member of the care team with whom the patient is able to schedule successive routine appointments

● Provide enhanced opportunities for the patient and any caregiver to communicate with the practitioner regarding the patient’s care by telephone and also through secure messaging, secure Internet, or other asynchronous non-face-to-face consultation methods (for example, email or secure electronic patient portal)
 Comprehensive Care Management

● Systematic assessment of the patient’s medical, functional, and psychosocial needs

● System-based approaches to ensure timely receipt of all recommended preventive care services

● Medication reconciliation with review of adherence and potential interactions

● Oversight of patient self-management of medications

● Coordinating care with home and community based clinical service providers


Transitional Care Management

● Manage transitions between and among health care providers and settings, including referrals to other clinicians, follow-up after an emergency department visit, or facility discharge

● Timely create and exchange/transmit continuity of care document(s) with other practitioners and providers Concurrent Billing

The billing practitioner cannot report both complex CCM and non-complex CCM for a given patient for a given calendar month. CCM cannot be billed during the same service period as HCPCS codes G0181/G0182 (home health care supervision/hospice care supervision), or CPT codes 90951–90970 (certain End-Stage Renal Disease services). CCM should not be reported for services furnished during the 30-day transitional care management service period (CPT 99495, 99496). Complex CCM and prolonged Evaluation and Management (E/M) services cannot be reported the same calendar month. Consult CPT instructions for additional codes that cannot be billed concurrent with CCM. There may be additional restrictions on billing for practitioners participating in a CMS sponsored model or demonstration program. Time that is reported under or counted
towards the reporting of a CCM service code cannot also be counted towards any other billed code.


Payment

CMS pays for CCM services separately under the Medicare PFS. To find payment information for a specific geographic location by code, access the Medicare PFS Look-Up tool at https://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/PFSlookup.

CCM and Other CMS Advanced Primary Care Initiatives

The CCM service codes provide payment of care coordination and care management for a patient with multiple chronic conditions within the Medicare Fee-For-Service Program. Medicare will not make duplicative payments for the same or similar services for patients with chronic conditions already paid for under the various CMS
advanced primary care demonstration and other initiatives, such as the Comprehensive Primary Care (CPC) Initiative. For more information on potentially duplicative billing, consult the CMS staff responsible for demonstration initiatives.


Initiating Visit – Initiation during an AWV, IPPE, or face-to-face E/M visit (Level 4 or 5 visit not required), for new patients or patients not seen within 1 year prior to the commencement of CCM services.


Structured Recording of Patient Information Using Certified EHR Technology – Structured recording of demographics, problems, medications, and medication allergies using certified EHR technology. A full list of problems, medications, and medication allergies in the EHR must inform the care plan, care coordination, and ongoing clinical care.


24/7 Access & Continuity of Care

● Provide 24/7 access to physicians or other qualified health care professionals or clinical staff including providing patients/caregivers with a means to make contact with health care professionals in the practice to address urgent needs regardless of the time of day or day of week

● Continuity of care with a designated member of the care team with whom the patient is able to schedule successive routine appointments


Comprehensive Care Management – Care management for chronic conditions including systematic assessment of the patient’s medical, functional, and psychosocial needs; system-based approaches to ensure timely receipt of all recommended preventive care services; medication reconciliation with review of adherence and potential interactions; and oversight of patient self-management of medications.


Comprehensive Care Plan

● Creation, revision, and/or monitoring (as per code descriptors) of an electronic person-centered care plan based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment and an inventory of resources and supports; a comprehensive care plan for all health issues with particular focus on the chronic conditions being managed.

● Must at least electronically capture care plan information, and make this information available timely within and outside the billing practice as appropriate. Share care plan information electronically (can include fax) and timely within and outside the billing practice to individuals involved in the patient’s care.

● A copy of the plan of care must be given to the patient and/or caregiver.


Management of Care Transitions

● Management of care transitions between and among health care providers and settings, including referrals to other clinicians; follow-up after an emergency department visit; and follow-up after discharges from hospitals, skilled nursing facilities, or other health care facilities ● Create and exchange/transmit continuity of care document(s) timely with other practitioners and providers


Home- and Community-Based Care Coordination

● Coordination with home- and community-based clinical service providers

● Communication to and from home- and community-based providers regarding the patient’s psychosocial needs and functional deficits must be documented in the patient’s medical record Enhanced Communication Opportunities – Enhanced opportunities for the patient and any caregiver to communicate with the practitioner regarding the patient’s care through not only telephone access, but also through the use of secure messaging, Internet, or other asynchronous non-face-to-face consultation
methods.


Patient Consent

● Inform the patient of the availability of CCM services; that only one practitioner can furnish and be paid for these services during a calendar month; and of their right to stop the CCM services at any time (effective at the end of the calendar month)

● Document in the patient’s medical record that the required information was explained and whether the patient accepted or declined the services


Medical Decision-Making – Complex CCM services require and include medical decision-making of moderate to high complexity (by the physician or other billing practitioner)


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