2023 HCPCS LEVEL II, PROFESSIONAL EDITION ISBN: 978-1-64016-228-0

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 DEVELOPMENT OF THIS EDITION

Lead Technical Collaborator

Jackie L. Koesterman, CPC
Coding and Reimbursement Specialist
JDK Medical Coding EDU
Grand Forks, North Dakota
 CONTENTS

INTRODUCTION

GUIDE TO USING THE 2023 HCPCS LEVEL II CODES

SYMBOLS AND CONVENTIONS

2023 HCPCS UPDATES

ANATOMY ILLUSTRATIONS

2023 HCPCS INDEX

2023 TABLE OF DRUGS

2023 HCPCS LEVEL II MODIFIERS

2023 HCPCS LEVEL II NATIONAL CODES

Appendix A—Jurisdiction List for DMEPOS HCPCS Codes

Appendix B—General Correct Coding Policies: National

Correct Coding Initiative Policy Manual for Medicaid Services

Figure Credits
Updates will be posted on codingupdates.com when available.

Check codingupdates.com for Practitioner and Facility Medically Unlikely Edits

(MUEs) and Column 1 and Column 2 Edits.

Check the Centers for Medicare & Medicaid Services

(www.cms.gov/Manuals/IOM/list.asp) website and codingupdates.com for full
and select IOMs.

Notice: 2023 DMEPOS updates were unavailable at the time of printing. Check
codingupdates.com for updates and DMEPOS Modifiers in January.
 INTRODUCTION

2023 HCPCS quarterly updates available on the companion

website at: www.codingupdates.com
The Centers for Medicare & Medicaid Services (CMS) (formerly Health Care
Financing Administration [HCFA]) Healthcare Common Procedure Coding
System (HCPCS) is a collection of codes and descriptors that represent
procedures, supplies, products, and services that may be provided to Medicare
beneficiaries and to individuals enrolled in private health insurance programs.
The codes are divided as follows:
Level I: Codes and descriptors copyrighted by the American Medical
Association’s (AMA’s) Current Procedural Terminology, ed. 4 (CPT-4). These
are five-digit numeric codes representing physician and nonphysician services.
Level II: Includes codes and descriptors copyrighted by the American Dental
Association’s current dental terminology, seventh edition (CDT-7/8). These are
five-digit alphanumeric codes comprising the D series. All other Level II
codes and descriptors are alphanumeric and approved and maintained jointly
by the editorial panel (consisting of CMS, the Health Insurance Association of
America, and the Blue Cross Blue Shield Association). These are five-digit
alphanumeric codes representing primarily items and nonphysician services
that are not represented in the Level I codes.
Level III: The CMS eliminated Level III local codes. See Program
Memorandum AB-02-113.
Headings are provided as a means of grouping similar or closely related items.
The placement of a code under a heading does not indicate additional means of
classification, nor does it relate to any health insurance coverage categories.
HCPCS also contains modifiers, which are two-digit codes and descriptors
used to indicate that a service or procedure that has been performed has been
altered by some specific circumstance but unchanged in its definition or code.
Modifiers are grouped by levels. Level I modifiers and descriptors are
copyrighted by the AMA. Level II modifiers are HCPCS modifiers. Modifiers in
the D series are copyrighted by the ADA.
HCPCS is designed to promote uniform reporting and statistical data
collection of medical procedures, supplies, products, and services.

HCPCS Disclaimer
Inclusion or exclusion of a procedure, supply, product, or service does not imply
any health insurance coverage or reimbursement policy.
HCPCS makes as much use as possible of generic descriptions, but the
inclusion of brand names to describe devices or drugs is intended only for
indexing purposes; it is not meant to convey endorsement of any particular
product or drug.

Updating HCPCS
The primary updates are made annually. Quarterly updates are also issued by
CMS.
 GUIDE TO USING THE 2023 HCPCS
LEVEL II CODES

Medical coding has long been a part of the health care profession. Through the
years medical coding systems have become more complex and extensive. Today,
medical coding is an intricate and immense process that is present in every health
care setting. The increased use of electronic submissions for health care services
only increases the need for coders who understand the coding process.
2023 HCPCS Level II was developed to help meet the needs of today’s coder.
All material adheres to the latest government versions available at the time of
printing.

Annotated
Throughout this text, revisions and additions are indicated by the following
symbols:
▶ New: Additions to the previous edition are indicated by the color
triangle.
Revised: Revisions within the line or code from the previous
edition are indicated by the color arrow.
✔ Reinstated indicates a code that was previously deleted and has
now been reactivated.
✖ Deleted words have been removed from this year’s edition.

HCPCS Symbols
❂ Special coverage instructions apply to these codes. Usually these
special coverage instructions are included in the Internet Only
Manuals (IOM). References to the IOM locations are given in the
form of Medicare Pub. 100 reference numbers listed below the
 code. IOM select references are located at codingupdates.com.
Not covered or valid by Medicare is indicated by the “No”
symbol. Usually the reason for the exclusion is included in the
Internet Only Manuals (IOM) select references at
codingupdates.com.
✽ Carrier discretion is an indication that you must contact the
individual third-party payers to find out the coverage available for
codes identified by this symbol.
Other Drugs approved for Medicare Part B and other FDA-approved
drugs are listed as Other.
A2-Z3 ASC Payment Indicators identify the 2019 final payment for the
code. A list of Payment Indicators is listed in the front matter of
this text.
A-Y OPPS Status Indicators identify the 2019 final status assigned to
the code. A list of Status Indicators is listed in the front matter of
this text.
Bill Part B MAC.
Bill DME MAC.
Coding Clinic Indicates the American Hospital Association Coding Clinic® for
HCPCS references by year, quarter, and page number.
DMEPOS identifies durable medical equipment, prosthetics,
orthotics, and supplies that may be eligible for payment from CMS.
♀ Indicates a code for female only.
♂ Indicates a code for male only.
Indicates a code with an indication of age.
Indicates a code included in the MIPS Quality Measure
Specifications.
Indicates there is a maximum allowable number of units of service,
per day, per patient for physician/provider services (see
codingupdates.com for Practitioner Medically Unlikely Edits).
Indicates there is a maximum allowable number of units of service,
per day, per patient in the outpatient hospital setting (see
codingupdates.com for Hospital Medically Unlikely Edits).
Red, green, and blue typeface terms within the Table of Drugs and
tabular section are terms added by the publisher and do not appear
in the official code set. Information supplementing the official
HCPCS Index produced by CMS is italicized.
SYMBOLS AND CONVENTIONS
Codes shown are for illustration purposes only and may not be current codes.

A2-Z3 ASC Payment Indicators

Final ASC Payment Indicators for CY 2023
Payment Payment Indicator Definition
Indicator
A2 Surgical procedure on ASC list in CY 2007; payment based on
OPPS relative payment weight.
B5 Alternative code may be available; no payment made.
D5 Deleted/discontinued code; no payment made.
F4 Corneal tissue acquisition, hepatitis B vaccine; paid at reasonable
cost.
G2 Non-office-based surgical procedure added in CY 2008 or later;
payment based on OPPS relative payment weight.
H2 Brachytherapy source paid separately when provided integral to a
surgical procedure on ASC list; payment OPPS rate.
J7 OPPS pass-through device paid separately when provided
integral to a surgical procedure on ASC list; payment contractor-
priced.
J8 Device-intensive procedure; paid at adjusted rate.
K2 Drugs and biologicals paid separately when provided integral to a
surgical procedure on ASC list; payment based on OPPS rate.
K5 Drugs and biologicals for which pricing information is not yet
available.
K7 Unclassified drugs and biologicals; payment contractor-priced.
L1 Influenza vaccine; pneumococcal vaccine. Packaged item/service;
no separate payment made.
L6 New Technology Intraocular Lens (NTIOL); special payment.
N1 Packaged service/item; no separate payment made.
P2 Office-based surgical procedure added to ASC list in CY 2008 or
later with MPFS nonfacility PE RVUs; payment based on OPPS
relative payment weight.
P3 Office-based surgical procedure added to ASC list in CY 2008 or
later with MPFS nonfacility PE RVUs; payment based on MPFS
nonfacility PE RVUs.
R2 Office-based surgical procedure added to ASC list in CY 2008 or
later without MPFS nonfacility PE RVUs; payment based on
OPPS relative payment weight.
Z2 Radiology or diagnostic service paid separately when provided
integral to a surgical procedure on ASC list; payment based on
OPPS relative payment weight.
 Z3 Radiology or diagnostic service paid separately when provided
integral to a surgical procedure on ASC list; payment based on
MPFS nonfacility PE RVUs.
CMS-1772-FC, Final Changes to the ASC Payment System and CY 2023 Payment Rates,
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/ASC-Regulations-and-
Notices.html.

A-Y OPPS Status Indicators

Final OPPS Payment Status Indicators for CY 2023
Indicator Item/Code/Service OPPS Payment Status
A Services furnished to a hospital Not paid under OPPS. Paid by
outpatient that are paid under a MACs under a fee schedule or
fee schedule or payment system payment system other than OPPS.
other than OPPS,* for example: Services are subject to deductible
or coinsurance unless indicated
otherwise.
• Ambulance Services
• Separately Payable Clinical Not subject to deductible or
Diagnostic Laboratory Services coinsurance.
• Separately Payable Non-
Implantable Prosthetics and
Orthotics
• Physical, Occupational, and
Speech Therapy
• Diagnostic Mammography
• Screening Mammography Not subject to deductible or
coinsurance.
B Codes that are not recognized by Not paid under OPPS.
OPPS when submitted on an
outpatient hospital Part B bill type • May be paid by MACs when
(12x and 13x) submitted on a different bill
type, for example, 75x (CORF),
but not paid under OPPS.
• An alternate code that is
recognized by OPPS when
submitted on an outpatient
hospital Part B bill type (12x
and 13x) may be available.
C Inpatient Procedures Not paid under OPPS. Admit
patient. Bill as inpatient.
D Discontinued Codes Not paid under OPPS or any other
Medicare payment system.
E1 Items, Codes and Services: Not paid by Medicare when
• Not covered by any Medicare submitted on outpatient claims
outpatient benefit category (any outpatient bill type).
• Statutorily excluded by
Medicare
• Not reasonable and necessary
E2 Items, Codes and Services: Not paid by Medicare when
for which pricing information and submitted on outpatient claims
claims data are not available (any outpatient bill type).
F Corneal Tissue Acquisition; Not paid under OPPS. Paid at
Certain CRNA Services and reasonable cost.
Hepatitis B Vaccines
G Pass-Through Drugs and Paid under OPPS; separate APC
Biologicals payment.
H Pass-Through Device Categories Separate cost-based pass-through
payment; not subject to
copayment.
J1 Hospital Part B services paid Paid under OPPS; all covered Part
through a comprehensive APC B services on the claim are
packaged with the primary “J1”
service for the claim, except
services with OPPS status
indicator of “F,” “G,” “H,” “L,”
and “U”; ambulance services;
diagnostic and screening
mammography; all preventive
services; and certain Part B
inpatient services.
J2 Hospital Part B Services That Paid under OPPS; Addendum B
May Be Paid Through a displays APC assignments when
Comprehensive APC services are separately payable.
(1) Comprehensive APC
payment based on OPPS
 comprehensive-specific
payment criteria. Payment for
all covered Part B services on
the claim is packaged into a
single payment for specific
combinations of services,
except services with OPPS
status indicator of “F,” “G,”
“H,” “L,” and “U”;
ambulance services;
diagnostic and screening
mammography; all preventive
services; and certain Part B
inpatient services.
(2) Packaged APC payment if
billed on the same claim as a
HCPCS code assigned status
indicator “J1.”
(3) In other circumstances,
payment is made through a
separate APC payment or
packaged into payment for
other services.
K Non-Pass-Through Drugs and Paid under OPPS: separate APC
Non-Implantable Biologicals, payment.
including Therapeutic
Radiopharmaceuticals
L Influenza Vaccine; Pneumococcal Not paid under OPPS. Paid at
Pneumonia Vaccine reasonable cost; not subject to
deductible or coinsurance.
M Items and Services Not Billable to Not paid under OPPS.
the MAC
N Items and Services Packaged into Paid under OPPS; payment is
APC Rates packaged into payment for other
services. Therefore, there is no
separate APC payment.
P Partial Hospitalization Paid under OPPS; per diem APC
payment.
Q1 STV-Packaged Codes Paid under OPPS; Addendum B
 displays APC assignments when
services are separately payable.
(1) Packaged APC payment if
billed on the same claim as a
HCPCS code assigned status
indicator “S,” “T,” or “V.”
(2) Composite APC payment if
billed with specific
combinations of services
based on OPPS composite-
specific payment criteria.
Payment is packaged into a
single payment for specific
combinations of services.
(3) In other circumstances,
payment is made through a
separate APC payment.
Q2 T-Packaged Codes Paid under OPPS; Addendum B
displays APC assignments when
services are separately payable.
(1) Packaged APC payment if
billed on the same claim as a
HCPCS code assigned status
indicator “T.”
(2) In other circumstances,
payment is made through a
separate APC payment.

Q3 Codes That May Be Paid Through Paid under OPPS; Addendum B

a Composite APC displays APC assignments when
services are separately payable.
Addendum M displays composite
APC assignments when codes are
paid through a composite APC.
(1) Composite APC payment
based on OPPS composite-
specific payment criteria.
Payment is packaged into a
single payment for specific
 combinations of service.
(2) In other circumstances,
payment is made through a
separate APC payment or
packaged into payment for
other services.
Q4 Conditionally packaged Paid under OPPS or CLFS.
laboratory tests
(1) Packaged APC payment if
billed on the same claim as a
HCPCS code assigned
published status indicator
“J1,” “J2,” “S,” “T,” “V,”
“Q1,” “Q2,” or “Q3.”
(2) In other circumstances,
laboratory tests should have
an SI=A and payment is made
under the CLFS.

R Blood and Blood Products Paid under OPPS; separate APC

payment.
S Procedure or Service, Not Paid under OPPS; separate APC
Discounted when Multiple payment.
T Procedure or Service, Multiple Paid under OPPS; separate APC
Procedure Reduction Applies payment.
U Brachytherapy Sources Paid under OPPS; separate APC
payment.
V Clinic or Emergency Department Paid under OPPS; separate APC
Visit payment.
Y Non-Implantable Durable Not paid under OPPS. All
Medical Equipment institutional providers other than
home health agencies bill to a
DME MAC.
* Note — Payments “under a fee schedule or payment system other than OPPS” may be contractor priced.
CMS-1772-FC, Final Changes to the ASC Payment System and CY 2023 Payment Rates,
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-
Regulations-and-Notices.html.
 2023 HCPCS
UPDATES

2023 HCPCS New/Revised/Deleted Codes

and Modifiers
HCPCS quarterly updates are posted on the companion website
(www.codingupdates.com) when available.

NEW CODES/MODIFIERS
AB
JZ
LU
A4239
C1747
C1826
C1827
C7500
C7501
C7502
C7503
C7504
C7505
C7506
C7507
C7508
C7509
C7510
C7511
C7512
C7513
C7514
C7515
C7516
C7517
C7518
C7519
C7520
C7521
C7522
C7523
C7524
C7525
C7526
C7527
C7528
C7529
C7530
C7531
C7532
C7533
C7534
C7535
C7537
C7538
C7539
C7540
C7541
C7542
C7543
C7544
C7545
C7546
C7547
C7548
C7549
C7550
C7551
C7552
C7553
C7554
C7555
C7900
C7901
C7902
C9143
C9144
E2103
G0316
G0317
G0318
G0320
G0321
G0322
G0323
G0330
G3002
G3003
J0134
J0136
J0173
J0225
J0283
J0611
J0689
J0701
J0703
J0877
J0891
J0892
J0893
J0898
J0899
J1456
J1574
J1611
J1643
J2021
J2184
J2247
J2251
J2272
J2281
J2311
J2327
J2401
J2402
J3244
J3371
J3372
J9046
J9048
J9049
J9393
J9394
M0001
M0002
M0003
M0004
M0005
M1150
M1151
M1152
M1153
M1154
M1155
M1156
M1157
M1158
M1159
M1160
M1161
M1162
M1163
M1164
M1165
M1166
M1167
M1168
M1169
M1170
M1171
M1172
M1173
M1174
M1175
M1176
M1177
M1178
M1179
M1180
M1181
M1182
M1183
M1184
M1185
M1186
M1187
M1188
M1189
M1190
M1191
M1192
M1193
M1194
M1195
M1196
M1197
M1198
M1199
M1200
M1201
M1202
M1203
M1204
M1205
M1206
M1207
M1208
M1209
M1210
Q4262
Q4263
Q4264
Q5126

REVISED CODES/MODIFIERS
JG
TB
A4238
A9276
A9277
A9278
C1831
C9761
E2102
G0029
G0030
G0442
G0444
G0917
G2136
G2137
G2138
G2139
G2140
G2141
G2146
G2147
G2152
G2167
G2174
G2182
G2199
G2202
G2204
G2207
G2210
G2212
G4013
G4020
G8451
G8539
G8543
G8600
G8601
G8602
G8633
G8647
G8648
G8650
G8651
G8652
G8654
G8655
G8656
G8658
G8659
G8660
G8662
G8663
G8664
G8666
G8667
G8668
G8670
G8694
G8708
G8710
G8711
G8734
G8826
G8842
G8843
G8844
G8852
G8854
G8923
G8934
G8942
G8968
G9315
G9404
G9407
G9418
G9500
G9501
G9624
G9626
G9662
G9663
G9781
G9789
G9847
G9848
G9905
G9906
G9908
G9913
G9943
G9946
G9949
G9968
G9969
G9970
G9990
G9991
G9993
J0131
J0610
J9041
M1003
M1052
 DELETED CODES/MODIFIERS
C1841
C1842
C1849
C9142
G0028
G0308
G0309
G2095
G2170
G2171
G2198
G2201
G2203
G9196
G9197
G9198
G9250
G9251
G9359
G9360
G9506
G9618
G9620
G9623
G9631
G9632
G9633
G9718
G9774
G9778
G9808
G9809
G9810
G9811
G9904
G9907
G9909
G9932
G9942
G9948
G9989
J2400
J9044
K0553
K0554
M1017
M1071
 NEW, REVISED, AND DELETED DENTAL CODES
New
D0372
D0373
D0374
D0387
D0388
D0389
D0801
D0802
D0803
D0804
D1781
D1782
D1783
D4286
D6105
D6106
D6107
D6197
D7509
D7956
D7957
D9953
Revised
D0210
D0709
D0393
D3333
D4240
D4241
D4355
D4921
D7251
D9450

Deleted
D0351
D0704
Plate 1 Cranial Nerves (12 pairs) are known by their numbers (Roman numerals) and names.
(Herlihy BL: The Human Body in Health and Illness, ed 6, St. Louis, 2018, Elsevier.)
Plate 2 Nerves of Orbit. (Copyright 2022 Elsevier Inc. All rights reserved.
www.netterimages.com. Image ID: 4615.)
Plate 3 Innervation of the Hand: Median and Ulnar Nerves (From Drake RL, Vogl AW,
Mitchell AWM, Tibbitts RM, Richardson PE: Gray’s Atlas of Anatomy, ed 2, Philadelphia,
2015, Churchill Livingstone.)
Plate 4 Arteries and Nerves of the Forearm (Anterior View) (From Drake RL, Vogl AW,
Mitchell AWM, Tibbitts RM, Richardson PE: Gray’s Atlas of Anatomy, ed 2, Philadelphia,
2015, Churchill Livingstone.)
Plate 5 Superficial Nerves and Veins of Lower Limb: Anterior View. (Copyright 2022
Elsevier Inc. All rights reserved. www.netterimages.com. Image ID: 4846.)
Plate 6 Superficial Nerves and Veins of Lower Limb: Posterior View. (Copyright 2022
Elsevier Inc. All rights reserved. www.netterimages.com. Image ID: 4669.)
Plate 7 Arteries and Nerves of Thigh: Anterior Views. (Copyright 2022 Elsevier Inc. All
rights reserved. www.netterimages.com. Image ID: 4475.)
Plate 8 Arteries and Nerves of Thigh: Posterior View. (Copyright 2022 Elsevier Inc. All
rights reserved. www.netterimages.com. Image ID: 49316.)
Plate 9 Arteries and Nerves of Thigh: Posterior View. (Copyright 2022 Elsevier Inc. All
rights reserved. www.netterimages.com. Image ID: 49317.)
Plate 10 Anatomy of the Eye. (Dehn RW, Asprey DP: Essential Clinical Procedures, ed 3,
Philadelphia, 2013, Saunders.)
Plate 11 Intrinsic Arteries and Veins of Eye. (Copyright 2022 Elsevier Inc. All rights
reserved. www.netterimages.com. Image ID: 49107.)
Plate 12 Anatomy of the Conjunctiva and Eyelids. (Kumar V, Abbas AK, Aster JC: Robbins
and Cotran Pathologic Basis of Disease, ed 9, Philadelphia, 2015, Saunders.)

Plate 13 Eyelid. (Copyright 2022 Elsevier Inc. All rights reserved. www.netterimages.com.
Image ID: 4557.)
Plate 14 Lacrimal Apparatus. (Copyright 2022 Elsevier Inc. All rights reserved.
www.netterimages.com. Image ID: 49103.)
Plate 15 Pathway of Sound. (LaFleur Brooks D, LaFleur Brooks M: Basic Medical
Language, ed 4, St. Louis, 2013, Mosby.)

Plate 16 Middle Ear Structures. (©Elsevier Collection.)

Plate 17 Structural Landmarks of Tympanic Membrane. (Ignatavicius DD, Workman ML:
Medical-Surgical Nursing: Patient-Centered Collaborative Care, ed 7, St. Louis, 2013,
Saunders.)

Plate 18 Inner Ear Structures. (©Elsevier Collection.)

Plate 19 The Tooth. (©Elsevier Collection).

Plate 20 Adult Teeth. (©Elsevier Collection).

Plate 21 A, Dorsal view of tongue showing the roughened large lingual tonsils on the
posterior of the tongue and the foliate papillae on the side. B, Section of dorsal of the tongue
showing a cutaway through lingual papillae and showing von Ebner’s glands at the base of
the vallate papilla. (Brand RW, Isselhard DE: Anatomy of Orofacial Structures: A
Comprehensive Approach, ed 8, St. Louis, 2019, Elsevier.)

Plate 22 Paranasal Sinuses. (Copyright 2022 Elsevier Inc. All rights reserved.
www.netterimages.com. Image ID: 8427.)
Plate 23 Salivary Glands. (Copyright 2022 Elsevier Inc. All rights reserved.
www.netterimages.com. Image ID: 4396.)
Plate 24 Coronary Arteries: Arteriographic Views. (Copyright 2022 Elsevier Inc. All rights
reserved. www.netterimages.com. Image ID: 4725.)
Plate 25 Coronary Arteries: Arteriographic Views. (Copyright 2022 Elsevier Inc. All rights
reserved. www.netterimages.com. Image ID: 4542.)
Plate 26 Arteries of Brain: Frontal View and Section. (Copyright 2022 Elsevier Inc. All
rights reserved. www.netterimages.com. Image ID: 4588.)
Plate 27 Mucosa and Musculature of Large Intestine. (Copyright 2022 Elsevier Inc. All
rights reserved. www.netterimages.com. Image ID: 4778.)
Plate 28 Cross Section of Thorax at T3-4 Disc Level. (Copyright 2022 Elsevier Inc. All
rights reserved. www.netterimages.com. Image ID: 4880.)
Plate 29 Knee joint opened; anterior, posterior, and proximal views. A, Anterior view of the
knee joint, opened by folding the patella and patellar ligament inferiorly. On the lateral side is
the fibular collateral ligament, separated by the popliteal tendon from the lateral meniscus.
On the medial side, the tibial collateral ligament is attached to the medial meniscus. The
anterior and posterior cruciate ligaments are seen between the femoral condyles. B, Posterior
view of the opened knee joint with a more complete view of the posterior cruciate ligament.
C, The femur is removed, showing the proximal (articular) end of the right tibia. On the
medial side is the gently curved medial meniscus; on the lateral side is the more tightly
curved lateral meniscus. The anterior end of the medial meniscus is anchored to the surface
of the tibia by the transverse ligament. The cut ends of the anterior and posterior cruciate
ligaments are shown, as well as the meniscofemoral ligament. (Fritz S: Mosby’s Essential
Sciences for Therapeutic Massage: Anatomy, Physiology, Biomechanics, and Pathology, ed
5, St. Louis, 2017, Elsevier.)
INDEX
 A
Abatacept, J0129
Abciximab, J0130
Abdomen
dressing holder/binder, A4461, A4463
pad, low profile, L1270
Abduction control, each, L2624
Abduction restrainer, A4566
Abduction rotation bar, foot, L3140–L3170
adjustable shoe style positioning device, L3160
including shoes, L3140
plastic, heel-stabilizer, off-shelf, L3170
without shoes, L3150
Abecma, Q2055
AbobotulinumtoxinA, J0586
Absorption dressing, A2001–A2010, A2015–A2018, A6251–A6256 ◀
Access, site, occlusive, device, G0269
Access system, A4301
Accessories
ambulation devices, E0153–E0159
crutch attachment, walker, E0157
forearm crutch, platform attachment, E0153
leg extension, walker, E0158
replacement, brake attachment, walker, E0159
seat attachment, walker, E0156
walker, platform attachment, E0154
wheel attachment, walker, per pair, E0155
artificial kidney and machine; (see also ESRD), E1510–E1699
adjustable chair, ESRD patients, E1570
automatic peritoneal dialysis system, intermittent, E1592
bath conductivity meter, hemodialysis, E1550
blood leak detector, hemodialysis, replacement, E1560
blood pump, hemodialysis, replacement, E1620
cycler dialysis machine, peritoneal, E1594
deionizer water system, hemodialysis, E1615
delivery/installation charges, hemodialysis equipment, E1600
hemodialysis machine, E1590
hemostats, E1637
 heparin infusion pump, hemodialysis, E1520
kidney machine, dialysate delivery system, E1510
peritoneal dialysis clamps, E1634
portable travel hemodialyzer, E1635
reciprocating peritoneal dialysis system, E1630
replacement, air bubble detector, hemodialysis, E1530
replacement, pressure alarm, hemodialysis, E1540
reverse osmosis water system, hemodialysis, E1610
scale, E1639
sorbent cartridges, hemodialysis, E1636
transducer protectors, E1575
unipuncture control system, E1580
water softening system, hemodialysis, E1625
wearable artificial kidney, E1632
beds, E0271–E0280, E0300–E0326
bed board, E0273
bed, board/table, E0315
bed cradle, E0280
bed pan, standard, E0275
bed side rails, E0305–E0310
bed-pan fracture, E0276
hospital bed, extra heavy duty, E0302, E0304
hospital bed, heavy duty, E0301–E0303
hospital bed, pediatric, electric, E0329
hospital bed, safety enclosure frame, E0316
mattress, foam rubber, E0272
mattress, innerspring, E0271
over-bed table, E0274
pediatric crib, E0300
powered pressure-reducing air mattress, E0277
wheelchairs, E0950–E1030, E1050–E1298, E2300–E2399, K0001–K0109
accessory tray, E0950
arm rest, E0994
back upholstery replacement, E0982
calf rest/pad, E0995
commode seat, E0968
detachable armrest, E0973
elevating leg rest, E0990
headrest cushion, E0955
lateral trunk/hip support, E0956
loop-holder, E0951–E0952
 manual swingaway, E1028
manual wheelchair, adapter, amputee, E0959
manual wheelchair, anti-rollback device, E0974
manual wheelchair, anti-tipping device, E0971
manual wheelchair, hand rim with projections, E0967
manual wheelchair, headrest extension, E0966
manual wheelchair, lever-activated, wheel drive, E0988
manual wheelchair, one-arm drive attachment, E0958
manual wheelchair, power add-on, E0983–E0984
manual wheelchair, push activated power assist, E0986
manual wheelchair, solid seat insert, E0992
medial thigh support, E0957
modification, pediatric size, E1011
narrowing device, E0969
No. 2 footplates, E0970
oxygen related accessories, E1352–E1406
positioning belt/safety belt/pelvic strap, E0978
power-seating system, E1002–E1010
reclining back addition, pediatric size wheelchair, E1014
residual limb support system, E1020
safety vest, E0980
seat lift mechanism, E0985
seat upholstery replacement, E0981
shock absorber, E1015–E1018
shoulder harness strap, E0960
ventilator tray, E1029–E1030
wheel lock brake extension, manual, E0961
wheelchair, amputee, accessories, E1170–E1200
wheelchair, fully inclining, accessories, E1050–E1093
wheelchair, heavy duty, accessories, E1280–E1298
wheelchair, lightweight, accessories, E1240–E1270
wheelchair, semi-reclining, accessories, E1100–E1110
wheelchair, special size, E1220–E1239
wheelchair, standard, accessories, E1130–E1161
whirlpool equipment, E1300–E1310
Ace type, elastic bandage, A6448–A6450
Acetaminophen, J0131, J0134, J0136 ◀
Acetazolamide sodium, J1120
Acetylcysteine
inhalation solution, J7604, J7608
injection, J0132
Activity, therapy, G0176
Acyclovir, J0133
Adalimumab, J0135
Additions to
fracture orthosis, L2180–L2192
abduction bar, L2300–L2310
adjustable motion knee joint, L2186
anterior swing band, L2335
BK socket, PTB and AFO, L2350
disk or dial lock, knee flexion, L2425
dorsiflexion and plantar flexion, L2220
dorsiflexion assist, L2210
drop lock, L2405
drop lock knee joint, L2182
extended steel shank, L2360
foot plate, stirrup attachment, L2250
hip joint, pelvic band, thigh flange, pelvic belt, L2192
integrated release mechanism, L2515
lacer custom-fabricated, L2320–L2330
lift loop, drop lock ring, L2492
limited ankle motion, L2200
limited motion knee joint, L2184
long tongue stirrup, L2265
lower extremity orthrosis, L2200–L2397
molded inner boot, L2280
offset knee joint, L2390
offset knee joint, heavy duty, L2395
Patten bottom, L2370
pelvic and thoracic control, L2570–L2680
plastic shoe insert with ankle joints, L2180
polycentric knee joint, L2387
pre-tibial shell, L2340
quadrilateral, L2188
ratchet lock knee extension, L2430
reinforced solid stirrup, L2260
rocker bottom, custom fabricated, L2232
round caliper/plate attachment, L2240
split flat caliper stirrups, L2230
straight knee joint, heavy duty, L2385
straight knee, or offset knee joints, L2405–L2492
suspension sleeve, L2397
 thigh/weight bearing, L2500–L2550
torsion control, ankle joint, L2375
torsion control, straight knee joint, L2380
varus/valgus correction, L2270–L2275
waist belt, L2190
general additions, orthosis, L2750–L2999
lower extremity, above knee section, soft interface, L2830
lower extremity, concentric adjustable torsion style mechanism, L2861
lower extremity, drop lock retainer, L2785
lower extremity, extension, per extension, per bar, L2760
lower extremity, femoral length sock, L2850
lower extremity, full kneecap, L2795
lower extremity, high strength, lightweight material, hybrid lamination, L2755
lower extremity, knee control, condylar pad, L2810
lower extremity, knee control, knee cap, medial or lateral, L2800
lower extremity orthrosis, non-corrosive finish, per bar, L2780
lower extremity orthrosis, NOS, L2999
lower extremity, plating chrome or nickel, per bar, L2750
lower extremity, soft interface, below knee, L2820
lower extremity, tibial length sock, L2840
orthotic side bar, disconnect device, L2768
Adenosine, J0151, J0153
Adhesive, A4364
bandage, A6413
disc or foam pad, A5126
remover, A4455, A4456
support, breast prosthesis, A4280
wound, closure, G0168
Adjunctive, dental, D9110–D9999
Administration, chemotherapy, Q0083–Q0085
both infusion and other technique, Q0085
infusion technique only, Q0084
other than infusion technique, Q0083
Administration, Part D
vaccine, hepatitis B, G0010
vaccine, influenza, G0008
vaccine, pneumococcal, G0009
Administrative, Miscellaneous and Investigational, A9000–A9999
alert or alarm device, A9280
artificial saliva, A9155
DME delivery set-up, A9901
 exercise equipment, A9300
external ambulatory insulin delivery system, A9274
foot pressure off loading/supportive device, A9283
helmets, A8000–A8004
home glucose disposable monitor, A9275
hot-water bottle, ice cap, heat wrap, A9273
miscellaneous DME, NOS, A9999
miscellaneous DME supply, A9900
monitoring feature/device, stand-alone or integrated, A9279
multiple vitamins, oral, per dose, A9153
non-covered item, A9270
non-prescription drugs, A9150
pediculosis treatment, topical, A9180
radiopharmaceuticals, A9500–A9700
reaching grabbing device, A9281
receiver, external, interstitial glucose monitoring system, A9278
sensor, invasive, interstitial continuous glucose monitoring, A9276
single vitamin/mineral trace element, A9152
spirometer, non-electronic, A9284
transmitter, interstitial continuous glucose monitoring system, A9277
wig, any type, A9282
wound suction, disposable, A9272
Admission, observation, G0379
Ado-trastuzumab, J9354
Adrenalin, J0171
Aducanumab-avwa, J0172 ◀
Aduhelm, J0172
Advanced life support, A0390, A0426, A0427, A0433
ALS2, A0433
ALS emergency transport, A0427
ALS mileage, A0390
ALS, non-emergency transport, A0426
Aerosol
compressor, E0571–E0572
compressor filter, A7013–A7014, K0178–K0179
mask, A7015, K0180
Afamelanotide implant, J7352
Aflibercept, J0178
AFO, E1815, E1830, L1900–L1990, L4392, L4396
Afstyla, J7210
Agalsidase beta, J0180
Aggrastat, J3245
A-hydroCort, J1710
Aid, hearing, V5030–V5263
Aide, home, health, G0156, S9122, T1021
home health aide/certified nurse assistant, in home, S9122
home health aide/certified nurse assistant, per visit, T1021
home health or hospital setting, G0156
Air bubble detector, dialysis, E1530
Air fluidized bed, E0194
Air pressure pad/mattress, E0186, E0197
Air travel and nonemergency transportation, A0140
Alarm
not otherwise classified, A9280
pressure, dialysis, E1540
Alatrofloxacin mesylate, J0200
Albumin, human, P9041, P9042
Albuterol
all formulations, inhalation solution, J7620
all formulations, inhalation solution, concentrated, J7610, J7611
all formulations, inhalation solution, unit dose, J7609, J7613
Alcohol, A4244
Alcohol wipes, A4245
Alcohol/substance, assessment, G0396, G0397, H0001, H0003, H0049
alcohol abuse structured assessment, greater than 30 min., G0397
alcohol abuse structured assessment, 15–30 min., G0396
alcohol and/or drug assessment, Medicaid, H0001
alcohol and/or drug screening; laboratory analysis, Medicaid, H0003
alcohol and/or drug screening, Medicaid, H0049
Aldesleukin (IL2), J9015
Alefacept, J0215
Alemtuzumab, J0202
Alert device, A9280
Alginate dressing, A6196–A6199
alginate, pad more than 48 sq. cm, A6198
alginate, pad size 16 sq. cm, A6196
alginate, pad size more than 16 sq. cm, A6197
alginate, wound filler, sterile, A6199
Alglucerase, J0205
Alglucosidase, J0220
Alglucosidase alfa, J0221
Allogen, Q4212
Alphanate, J7186
Alpha-1–proteinase inhibitor, human, J0256, J0257
Alprostadil
injection, J0270
urethral suppository, J0275
ALS mileage, A0390
Alteplase recombinant, J2997
Alternating pressure mattress/pad, A4640, E0180, E0181, E0277
overlay/pad, alternating, pump, heavy duty, E0181
powered pressure-reducing air mattress, E0277
replacement pad, owned by patient, A4640
Alveoloplasty, D7310–D7321
in conjunction with extractions, four or more teeth, D7310
in conjunction with extractions, one to three teeth, D7311
not in conjunction with extractions, four or more teeth, D7320
not in conjunction with extractions, one to three teeth, D7321
Alymsys, Q5126 ◀
Amalgam dental restoration, D2140–D2161
four or more surfaces, primary or permanent, D2161
one surface, primary or permanent, D2140
three surfaces, primary or permanent, D2160
two surfaces, primary or permanent, D2150
Ambulance, A0021–A0999
air, A0430, A0431, A0435, A0436
conventional, transport, one way, fixed wing, A0430
conventional, transport, one way, rotary wing, A0431
fixed wing air mileage, A0435
rotary wing air mileage, A0436
disposable supplies, A0382–A0398
ALS routine disposable supplies, A0398
ALS specialized service disposable supplies, A0394
ALS specialized service, esophageal intubation, A0396
BLS routine disposable, A0832
BLS specialized service disposable supplies, defibrillation, A0384, A0392
non-emergency transport, fixed wing, S9960
non-emergency transport, rotary wing, S9961
oxygen, A0422
Ambulation device, E0100–E0159
brake attachment, wheeled walker replacement, E0159
cane, adjustable or fixed, with tip, E0100
cane, quad or three prong, adjustable or fixed, with tip, E0105
 crutch attachment, walker, E0157
crutch forearm, each, with tips and handgrips, E0111
crutch substitute, lower leg platform, with or without wheels, each, E0118
crutch, underarm, articulating, spring assisted, each, E0117
crutches forearm, pair, tips and handgrips, E0110
crutches, underarm, other than wood, pair, with pads, tips and handgrips, E0114
crutches, underarm, other than wood, with pad, tip, handgrip, with or without shock
absorber, each, E0116
crutches, underarm, wood, each, with pad, tip and handgrip, E0113
leg extensions, walker, set (4), E0158
platform attachment, forearm crutch, each, E0153
platform attachment, walker, E0154
seat attachment, walker, E0156
walker, enclosed, four-sided frame, wheeled, posterior seat, E0144
walker, folding, adjustable or fixed height, E0135
walker, folding, wheeled, adjustable or fixed height, E0143
walker, heavy duty, multiple braking system, variable wheel resistance, E0147
walker, heavy duty, wheeled, rigid or folding, E0149
walker, heavy duty, without wheels, rigid or folding, E0148
walker, rigid, adjustable or fixed height, E0130
walker, rigid, wheeled, adjustable or fixed height, E0141
walker, with trunk support, adjystable or fixed height, any, E0140
wheel attachment, rigid, pick up walker, per pair, E0155
Amikacin Sulfate, J0278
Aminolevulinate, J7309
Aminolevulinic acid HCl, J7308
Aminophylline, J0280
Aminolevulinic
Ameluz, J7345
Amiodarone HCl, J0282, J0283 ◀
Amitriptyline HCl, J1320
Ammonia N-13, A9526
Ammonia test paper, A4774
Amnioiwrap2, Q4221
Amnion Bio, Q4211
Amniotic membrane, V2790
Amobarbital, J0300
Amphotericin B, J0285
Lipid Complex, J0287–J0289
Ampicillin
sodium, J0290
 sodium/sulbactam sodium, J0295
Amputee
adapter, wheelchair, E0959
prosthesis, L5000–L7510, L7520, L7900, L8400–L8465
above knee, L5200–L5230
additions to exoskeletal knee-shin systems, L5710–L5782
additions to lower extremity, L5610–L5617
additions to socket insert and suspension, L5654–L5699
additions to socket variations, L5630–L5653
additions to test sockets, L5618–L5629
additions/replacements feet-ankle units, L5700–L5707
ankle, L5050–L5060
below knee, L5100–L5105
component modification, L5785–L5795
endoskeletal, L5810–L5999
endoskeleton, below knee, L5301–L5312
endoskeleton, hip disarticulation, L5331–L5341
fitting endoskeleton, above knee, L5321
fitting procedures, L5400–L5460
hemipelvectomy, L5280
hip disarticulation, L5250–L5270
initial prosthesis, L5500–L5505
knee disarticulation, L5150–L5160
male vacuum erection system, L7900
partial foot, L5000–L5020
preparatory prosthesis, L5510–L5600
prosthetic socks, L8400–L8485
repair, prosthetic device, L7520
tension ring, vacuum erection device, L7902
upper extremity, battery components, L7360–L7368
upper extremity, other/repair, L7400–L7510
upper extremity, preparatory, elbow, L6584–L6586
upper limb, above elbow, L6250
upper limb, additions, L6600–L6698
upper limb, below elbow, L6100–L6130
upper limb, elbow disarticulation, L6200–L6205
upper limb, endoskeletal, above elbow, L6500
upper limb, endoskeletal, below elbow, L6400
upper limb, endoskeletal, elbow disarticulation, L6450
upper limb, endoskeletal, interscapular thoracic, L6570
upper limb, endoskeletal, shoulder disarticulation, L6550
 upper limb, external power, device, L6920–L6975
upper limb, interscapular thoracic, L6350–L6370
upper limb, partial hand, L6000–L6025
upper limb, postsurgical procedures, L6380–L6388
upper limb, preparatory, shoulder, interscapular, L6588–L6590
upper limb, preparatory, wrist, L6580–L6582
upper limb, shoulder disarticulation, L6300–L6320
upper limb, terminal devices, L6703–L6915, L7007–L7261
upper limb, wrist disarticulation, L6050–L6055
stump sock, L8470–L8485
single ply, fitting above knee, L8480
single ply, fitting, below knee, L8470
single ply, fitting, upper limb, L8485
wheelchair, E1170–E1190, E1200, K0100
detachable arms, swing away detachable elevating footrests, E1190
detachable arms, swing away detachable footrests, E1180
detachable arms, without footrests or legrest, E1172
detachable elevating legrest, fixed full length arms, E1170
fixed full length arms, swing away detachable footrest, E1200
heavy duty wheelchair, swing away detachable elevating legrests, E1195
without footrests or legrest, fixed full length arms, E1171
Amygdalin, J3570
Anadulafungin, J0348
Analgesia, dental, D9230
Analysis
saliva, D0418
semen, G0027
Anaphylaxis, due to vaccine, M1160–M1161, M1163 ◀
Angiography, iliac, artery, G0278
Angiography, renal, non-selective, G0275
non-ophthalmic fluorescent vascular, C9733
reconstruction, G0288
Angioplasty, C7531–C7535 ◀
Anistreplase, J0350
Ankle splint, recumbent, K0126–K0130
Ankle-foot orthosis (AFO), L1900–L1990, L2106–L2116, L4361, L4392, L4396
ankle gauntlet, custom fabricated, L1904
ankle gauntlet, prefabricated, off-shelf, L1902
double upright free plantar dorsiflexion, olid stirrup, calf-band/cuff, custom, L1990
fracture orthrosis, tibial fracture, thermoplastic cast material, custom, L2106
multiligamentus ankle support, prefabricated, off-shelf, L1906
 plastic or other material, custom fabricated, L1940
plastic or other material, prefabricated, fitting and adjustment, L1932, L1951
plastic or other material, with ankle joint, prefabricated, fitting and adjustment, L1971
plastic, rigid anterior tibial section, custom fabricated, L1945
plastic, with ankle joint, custom, L1970
posterior, single bar, clasp attachment to shoe, L1910
posterior, solid ankle, plastic, custom, L1960
replacement, soft interface material, static AFO, L4392
single upright free plantar dorsiflection, solid stirrup, calf-band/cuff, custom, L1980
single upright with static or adjustable stop, custom, L1920
spiral, plastic, custom fabricated, L1950
spring wire, dorsiflexion assist calf band, L1900
static or dynamic AFO, adjustable for fit, minimal ambulation, L4396
supramalleolar with straps, custom fabricated, L1907
tibial fracture cast orthrosis, custom, L2108
tibial fracture orthrosis, rigid, prefabricated, fitting and adjustment, L2116
tibial fracture orthrosis, semi-rigid, prefabricated, fitting and adjustment, L2114
tibial fracture orthrosis, soft prefabricated, fitting and adjustment, L2112
walking boot, prefabricated, off-the-shelf, L4361
Anterior-posterior-lateral orthosis, L0700, L0710
Antibiotic, G8708–G8712
antibiotic not prescribed or dispensed, G8712
patient not prescribed or dispensed antibiotic, G8708
patient prescribed antibiotic, documented condition, G8709
patient prescribed or dispensed antibiotic, G8710
prescribed or dispensed antibiotic, G8711
Antidepressant, documentation, G8126–G8128
Anti-emetic, oral, J8498, J8597, Q0163–Q0181
antiemetic drug, oral NOS, J8597
antiemetic drug, rectal suppository, NOS, J8498
diphenhydramine hydrochloride, 50 mg, oral, Q0163
dolasetron mesylate, 100 mg, oral, Q0180
dronabinol, 2.5 mg, Q0167
granisetron hydrochloride, 1 mg, oral, Q0166
hydroxyzine pomoate, 25 mg, oral, Q0177
perphenazine, 4 mg, oral, Q0175
prochlorperazine maleate, 5 mg, oral, Q0164
promethazine hydrochloride, 12.5 mg, oral, Q0169
thiethylperazine maleate, 10 mg, oral, Q0174
trimethobenzamide hydrochloride, 250 mg, oral, Q0173
unspecified oral dose, Q0181
Anti-hemophilic factor (Factor VIII), J7190–J7192
Anti-inhibitors, per I.U., J7198
Antimicrobial, prophylaxis, documentation, D4281, G8201
Anti-neoplastic drug, NOC, J9999
Antithrombin III, J7197
Antithrombin recombinant, J7196
Antral fistula closure, oral, D7260
Apexification, dental, D3351–D3353
Apicoectomy, D3410–D3426
anterior, periradicular surgery, D3410
biscuspid (first root), D3421
(each additional root), D3426
molar (first root), D3425
Apomorphine, J0364
Appliance
cleaner, A5131
pneumatic, E0655–E0673
non-segmental pneumatic appliance, E0655, E0660, E0665, E0666
segmental gradient pressure, pneumatic appliance, E0671–E0673
segmental pneumatic appliance, E0656–E0657, E0667–E0670
Application, heat, cold, E0200–E0239
electric heat pad, moist, E0215
electric heat pad, standard, E0210
heat lamp with stand, E0205
heat lamp without stand, E0200
hydrocollator unit, pads, E0225
hydrocollator unit, portable, E0239
infrared heating pad system, E0221
non-contact wound warming device, E0231
paraffin bath unit, E0235
phototherapy (bilirubin), E0202
pump for water circulating pad, E0236
therapeutic lightbox, E0203
warming card, E0232
water circulating cold pad with pump, E0218
water circulating heat pad with pump, E0217
Aprotinin, J0365
Aqueous
shunt, L8612
sterile, J7051
ARB/ACE therapy, G8473–G8475
Arbutamine HCl, J0395
Arch support, L3040–L3100
hallus-valgus night dynamic splint, off-shelf, L3100
intralesional, J3302
non-removable, attached to shoe, longitudinal, L3070
non-removable, attached to shoe, longitudinal/metatarsal, each, L3090
non-removable, attached to shoe, metatarsal, L3080
removable, premolded, longitudinal, L3040
removable, premolded, longitudinal/metatarsal, each, L3060
removable, premolded, metatarsal, L3050
Arformoterol, J7605
Argatroban, J0883–J0884, J0891–J0892, J0898–J0899 ◀
Aripiprazole, J0400, J0401
Aripiprazol lauroxil, (aristada), J1944
aristada initio, H1943
Arm, wheelchair, E0973
Arsenic trioxide, J9017
Artacent cord, Q4216
Arthrography, injection, sacroiliac, joint, G0259, G0260
Arthroscopy, knee, surgical, G0289, S2112
chondroplasty, different compartment, knee, G0289
harvesting of cartilage, knee, S2112
Artificial
cornea, L8609
heart system, miscellaneous component, supply or accessory, L8698
kidney machines and accessories (see also Dialysis), E1510–E1699
larynx, L8500
saliva, A9155
Ascent, Q4213
Asparaginase, J9019–J9021 ◀
Aspirator, VABRA, A4480
Assessment
alcohol/substance (see also Alcohol/substance, assessment), G0396, G0397, H0001,
H0003, H0049
assessment for hearing aid, V5010
audiologic, V5008–V5020
cardiac output, M0302
conformity evaluation, V5020
fitting/orientation, hearing aid, V5014
hearing screening, V5008
itch severity, M1197–M1198, M1205–M1206 ◀
 repair/modification hearing aid, V5014
speech, V5362–V5364
Assistive listening devices and accessories, V5281–V5290
FMlDM system, monaural, V5281
Astramorph, J2275
Atezolizumab, J9022
Atherectomy, PTCA, C9602, C9603
Atropine
inhalation solution, concentrated, J7635
inhalation solution, unit dose, J7636
Atropine sulfate, J0461
Attachment, walker, E0154–E0159
brake attachment, wheeled walker, replacement, E0159
crutch attachment, walker, E0157
leg extension, walker, E0158
platform attachment, walker, E0154
seat attachment, walker, E0156
wheel attachment, rigid pick up walker, E0155
Audiologic assessment, V5008–V5020
Auditory osseointegrated device, L8690–L8694
Auricular prosthesis, D5914, D5927
Aurothioglucose, J2910
Avalglucosidase alfa-ngpt, J0219 ◀
Avelumab, J9023
Axobiomembrane, Q4211
Axolotl ambient or axolotl cryo, Q4215
Axolotl graft or axolotl dualgraft, Q4210
Azacitidine, J9025
Azathioprine, J7500, J7501
Azithromycin injection, J0456

B
Back supports, L0621–L0861, L0960
lumbar orthrosis, L0625–L0627
lumbar orthrosis, sagittal control, L0641–L0648
lumbar-sacral orthrosis, L0628–L0640
lumbar-sacral orthrosis, sagittal-coronal control, L0640, L0649–L0651
sacroiliac orthrosis, L0621–L0624
Baclofen, J0475, J0476
Bacterial sensitivity study, P7001
Bag
drainage, A4357
enema, A4458
irrigation supply, A4398
urinary, A4358, A5112
Bandage, conforming
elastic, >5″, A6450
elastic, >3″, <5″, A6449
elastic, load resistance 1.25 to 1.34 foot pounds, >3″, <5″, A6451
elastic, load resistance <1.35 foot pounds, >3″, <5″, A6452
elastic, <3″, A6448
non-elastic, non-sterile, >5″, A6444
non-elastic, non-sterile, width greater than or equal to 3″, <5″, A6443
non-elastic, non-sterile, width <3″, A6442
non-elastic, sterile, >5″, A6447
non-elastic, sterile, >3″ and <5″, A6446
Bamlan and etesev, M0245
Bamlanivimab and etesevima, Q0245
Basiliximab, J0480
Bath, aid, E0160–E0162, E0235, E0240–E0249
bath tub rail, floor base, E0242
bath tub wall rail, E0241
bath/shower chair, with/without wheels, E0240
pad for water circulating heat unit, replacement, E0249
paraffin bath unit, portable, E0235
raised toilet seat, E0244
sitz bath chair, E0162
sitz type bath, portable, with faucet attachment, E0161
sitz type bath, portable, with/without commode, E0160
toilet rail, E0243
transfer bench, tub or toilet, E0248
transfer tub rail attachment, E0246
tub stool or bench, E0245
Bathtub
chair, E0240
stool or bench, E0245, E0247–E0248
transfer rail, E0246
wall rail, E0241–E0242
Battery, L7360, L7364–L7368
charger, E1066, L7362, L7366
 replacement for blood glucose monitor, A4233–A4236
replacement for cochlear implant device, L8618, L8623–L8625
replacement for TENS, A4630
ventilator, A4611–A4613
Bebtelovimab, M0222–M0223, Q0222 ◀
Beclomethasone inhalation solution, J7622
Bed
accessories, E0271–E0280, E0300–E0326
bed board, E0273
bed cradle, E0280
bed pan, fracture, metal, E0276
bed pan, standard, metal, E0275
mattress, foam rubber, E0272
mattress innerspring, E0271
over-bed table, E0274
power pressure-reducing air mattress, E0277
air fluidized, E0194
cradle, any type, E0280
drainage bag, bottle, A4357, A5102
hospital, E0250–E0270, E0300–E0329
pan, E0275, E0276
rail, E0305, E0310
safety enclosure frame/canopy, E0316
Behavioral, health, treatment services (Medicaid), H0002–H2037
activity therapy, H2032
alcohol/drug services, H0001, H0003, H0005–H0016, H0020–H0022, H0026–H0029,
H0049–H0050, H2034–H2036
assertive community treatment, H0040
community based wrap-around services, H2021–H2022
comprehensive community support, H2015–H2016
comprehensive medication services, H2010
comprehensive multidisciplinary evaluation, H2000
crisis intervention, H2011
day treatment, per diem, H2013
day treatment, per hour, H2012
developmental delay prevention activities, dependent child of client, H2037
family assessment, H1011
foster care, child, H0041–H0042
health screening, H0002
hotline service, H0030
medication training, H0034
 mental health clubhouse services, H2030–H2031
multisystemic therapy, juveniles, H2033
non-medical family planning, H1010
outreach service, H0023
partial hospitalization, H0035
plan development, non-physician, H0033
prenatal care, at risk, H1000–H1005
prevention, H0024–H0025
psychiatric supportive treatment, community, H0036–H0037
psychoeducational service, H2027
psychoscial rehabilitation, H2017–H2018
rehabilitation program, H2010
residential treatment program, H0017–H0019
respite care, not home, H0045
self-help/peer services, H0039
sexual offender treatment, H2028–H2029
skill training, H2014
supported employment, H2024–H2026
supported housing, H0043–H0044
therapeutic behavioral services, H2019–H2020
Behavioral therapy, cardiovascular disease, G0446
Belatacept, J0485
Belimumab, J0490
Bellacell, Q4220
Belt
belt, strap, sleeve, garment, or covering, any type, A4467
extremity, E0945
ostomy, A4367
pelvic, E0944
safety, K0031
wheelchair, E0978, E0979
Bench, bathtub; (see also Bathtub), E0245
Bendamustine HCl
Bendeka, 1 mg, J9034
Treanda, 1 mg, J9033
Bendamustine HCI (Belrapzo/bendamustine), J9036
Benesch boot, L3212–L3214
Benztropine, J0515
Beta-blocker therapy, G9188–G9192
Betadine, A4246, A4247
Betameth, J0704
Betamethasone
acetate and betamethasone sodium phosphate, J0702
inhalation solution, J7624
Bethanechol chloride, J0520
Bevacizumab, J9035, Q2024
bvzr (Zirabez), Q5118
Bezlotoxuman, J0565
Bicuspid (excluding final restoration), D3320
retreatment, by report, D3347
surgery, first root, D3421
Bifocal, glass or plastic, V2200–V2299
aniseikonic, bifocal, V2218
bifocal add-over 3.25 d, V2220
bifocal seg width over 28 mm, V2219
lenticular, bifocal, myodisc, V2215
lenticular lens, V2221
specialty bifocal, by report, V2200
sphere, bifocal, V2200–V2202
spherocylinder, bifocal, V2203–V2214
Bilirubin (phototherapy) light, E0202
Binder, A4465
Biofeedback device, E0746
Bioimpedance, electrical, cardiac output, M0302
Biosimilar (infliximab), Q5102–Q5124 ◀
BioWound, Q4217
Biperiden lactate, J0190
Bitewing, D0270–D0277
four radiographic images, D0274
single radiographic image, D0270
three radiographic images, D0273
two radiographic images, D0272
vertical bitewings, 7–8 radiographic images, D0277
Bitolterol mesylate, inhalation solution
concentrated, J7628
unit dose, J7629
Bivalirudin, J0583
Bivigam, 500 mg, J1556
Bladder calculi irrigation solution, Q2004
Bleomycin sulfate, J9040
Blood
count, G0306, G0307, S3630
 complete CBC, automated, without platelet count, G0307
complete CBC, automated without platelet count, automated WBC differential, G0306
eosinophil count, blood, direct, S3630
component/product not otherwise classified, P9099
fresh frozen plasma, P9017
glucose monitor, E0607, E2100–E2102, S1030, S1031, S1034
blood glucose monitor, integrated voice synthesizer, E2100
blood glucose monitor with integrated lancing/blood sample, E2101
continuous noninvasive device, purchase, S1030
continuous noninvasive device, rental, S1031
home blood glucose monitor, E0607
glucose test, A4253
glucose, test strips, dialysis, A4772
granulocytes, pheresis, P9050
ketone test, A4252
leak detector, dialysis, E1560
leukocyte poor, P9016
mucoprotein, P2038
platelets, P9019
platelets, irradiated, P9032
platelets, leukocytes reduced, P9031
platelets, leukocytes reduced, irradiated, P9033
platelets, pheresis, P9034, P9072, P9073, P9100
platelets, pheresis, irradiated, P9036
platelets, pheresis, leukocytes reduced, P9035
platelets, pheresis, leukocytes reduced, irradiated, P9037
pressure monitor, A4660, A4663, A4670
pump, dialysis, E1620
red blood cells, deglycerolized, P9039
red blood cells, irradiated, P9038
red blood cells, leukocytes reduced, P9016
red blood cells, leukocytes reduced, irradiated, P9040
red blood cells, washed, P9022
strips, A4253
supply, P9010–P9022
testing supplies, A4770
tubing, A4750, A4755
Blood collection devices accessory, A4257, E0620
BMI, G8417–G8422
Body jacket
scoliosis, L1300, L1310
Body mass index, G8417–G8422
Body sock, L0984
Bond or cement, ostomy skin, A4364
Bone
density, study, G0130
Boot
pelvic, E0944
surgical, ambulatory, L3260
Bortezomib, J9041, J9046, J9048–J9049 ◀
Brachytherapy radioelements, Q3001
brachytherapy, LDR, prostate, G0458
brachytherapy planar source, C2645
brachytherapy, source, hospital outpatient, C1716–C1717, C1719
Breast prosthesis, L8000–L8035, L8600
adhesive skin support, A4280
custom breast prosthesis, post mastectomy, L8035
garment with mastectomy form, post mastectomy, L8015
implantable, silicone or equal, L8600
mastectomy bra, with integrated breast prosthesis form, unilateral, L8001
mastectomy bra, with prosthesis form, bilateral, L8002
mastectomy bra, without integrated breast prosthesis form, L8000
mastectomy form, L8020
mastectomy sleeve, L8010
nipple prosthesis, L8032
silicone or equal, with integral adhesive, L8031
silicone or equal, without integral adhesive, L8030
Breast pump
accessories, A4281–A4286
adapter, replacement, A4282
cap, breast pump bottle, replacement, A4283
locking ring, replacement, A4286
polycarbonate bottle, replacement, A4285
shield and splash protector, replacement, A4284
tubing, replacement, A4281
electric, any type, E0603
heavy duty, hospital grade, E0604
manual, any type, E0602
Breathing circuit, A4618
Brentuximab Vedotin, J9042
Brexanolone, J1632
Bridge
 repair, by report, D6980
replacement, D6930
Bronchoscopy, C7509–C7512 ◀
Brolucizumab-dbll, J0179
Brompheniramine maleate, J0945
Budesonide inhalation solution, J7626, J7627, J7633, J7634
Bulking agent, L8604, L8607
Bupivacaine, C9144 ◀
Buprenorphine hydrochlorides, J0592
Buprenorphine/Naloxone, J0571–J0575
Burn, compression garment, A6501–A6513
bodysuit, head-foot, A6501
burn mask, face and/or neck, A6513
chin strap, A6502
facial hood, A6503
foot to knee length, A6507
foot to thigh length, A6508
glove to axilla, A6506
glove to elbow, A6505
glove to wrist, A6504
lower trunk, including leg openings, A6511
trunk, including arms, down to leg openings, A6510
upper trunk to waist, including arm openings, A6509
Bus, nonemergency transportation, A0110
Busulfan, J0594, J8510
Butorphanol tartrate, J0595
Bypass, graft, coronary, artery
surgery, S2205–S2209

C
C-1 Esterase Inhibitor, J0596–J0598
Cabazitaxel, J9043
Cabergoline, oral, J8515
Cabinet/System, ultraviolet, E0691–E0694
multidirectional light system, 6 ft. cabinet, E0694
timer and eye protection, 4 foot, E0692
timer and eye protection, 6 foot, E0693
ultraviolet light therapy system, treatment area 2 sq ft., E0691
Cabote rilpivir J0741
Cabotegravir, J0739 ◀
Caffeine citrate, J0706
Calaspargase pegol injection-mknl, J9118
Calcitonin-salmon, J0630
Calcitriol, J0636, S0169
Calcium
disodium edetate, J0600
gluconate, J0610, J0611 ◀
glycerophosphate and calcium lactate, J0620
lactate and calcium glycerophosphate, J0620
leucovorin, J0640
Calibrator solution, A4256
Camcevi, J1952
Canakinumab, J0638
Cancer, screening
cervical or vaginal, G0101
colorectal, G0104–G0106, G0120–G0122, G0328
alternative to screening colonoscopy, barium enema, G0120
alternative to screening sigmoidoscopy, barium enema, G0106
barium enema, G0122
colonoscopy, high risk, G0105
colonoscopy, not at high-risk, G0121
fecal occult blood test, 1-3 simultaneous, G0328
flexible sigmoidoscopy, G0104
prostate, G0102, G0103
Cane, E0100, E0105
accessory, A4636, A4637
Canister
disposable, used with suction pump, A7000
non-disposable, used with suction pump, A7001
Cannula, nasal, A4615
Capecitabine, oral, J8520, J8521
Capsaicin patch, J7336
Carbidopa 5 mg/levodopa 20 mg enteral suspension, J7340
Carbon filter, A4680
Carboplatin, J9045
Cardia Event, recorder, implantable, E0616
Cardiokymography, Q0035
Cardiovascular services, M0300–M0301
Fabric wrapping abdominal aneurysm, M0301
IV chelation therapy, M0300
Cardioverter-defibrillator, G0448
Care ◀
cancer, M0001 ◀
optimal, M0002–M0003 ◀
supportive, M0004 ◀
Care, coordinated, G9001–G9011, H1002
coordinated care fee, home monitoring, G9006
coordinated care fee, initial rate, G9001
coordinated care fee, maintenance rate, G9002
coordinated care fee, physician coordinated care oversight, G9008
coordinated care fee, risk adjusted high, initial, G9003
coordinated care fee, risk adjusted low, initial, G9004
coordinated care fee, risk adjusted maintenance, G9005
coordinated care fee, risk adjusted maintenance, level 3, G9009
coordinated care fee, risk adjusted maintenance, level 4, G9010
coordinated care fee, risk adjusted maintenance, level 5, G9011
coordinated care fee, scheduled team conference, G9007
prenatal care, at-risk, enhanced service, care coordination, H1002
Care plan, G0162
Carfilzomib, J9047
Caries susceptibility test, D0425
Carmustine, J9050
Case management, T1016, T1017
behavioral health, G0323 ◀
dental, D9991–D9994
Casimersen J1426
Caspofungin acetate, J0637
Cast
diagnostic, dental, D0470
hand restoration, L6900–L6915
materials, special, A4590
supplies, A4580, A4590, Q4001–Q4051
body cast, adult, Q4001–Q4002
cast supplies (e.g., plaster), A4580
cast supplies, unlisted types, Q4050
finger splint, static, Q4049
gauntlet cast, adult, Q4013–Q4014
gauntlet cast, pediatric, Q4015–Q4016
hip spica, adult, Q4025–Q4026
hip spica, pediatric, Q4027–Q4028
long arm cast, adult, Q4005–Q4006
 long arm cast, pediatric, Q4007–Q4008
long arm splint, adult, Q4017–Q4018
long arm splint, pediatric, Q4019–Q4020
long leg cast, adult, Q4029–Q4030
long leg cast, pediatric, Q4031–Q4032
long leg cylinder cast, adult, Q4033–Q4034
long leg cylinder cast, pediatric, Q4035–Q4036
long leg splint, adult, Q4041–Q4042
long leg splint, pediatric, Q4043–Q4044
short arm cast, adult, Q4009–Q4010
short arm cast, pediatric, Q4011–Q4012
short arm splint, adult, Q4021–Q4022
short arm splint, pediatric, Q4023–Q4024
short leg cast, adult, Q4037–Q4038
short leg cast, pediatric, Q4039–Q4040
short leg splint, adult, Q4045–Q4046
short leg splint, pediatric, Q4047–Q4048
shoulder cast, adult, Q4003–Q4004
special casting material (fiberglass), A4590
splint supplies, miscellaneous, Q4051
thermoplastic, L2106, L2126
Caster
front, for power wheelchair, K0099
wheelchair, E0997, E0998
Catheter, A4300–A4355
anchoring device, A4333, A4334, A5200
cap, disposable (dialysis), A4860
convert, C7547 ◀
coronary artery, C7516–C7529, C7552–C7553 ◀
exchange, C7548 ◀
external collection device, A4327–A4330, A4347–A7048
female external, A4327–A4328
indwelling, A4338–A4346
insertion tray, A4354
insulin infusion catheter, A4224
intermittent with insertion supplies, A4353
irrigation supplies, A4355
male external, A4324, A4325, A4326, A4348
nephroureteral, C7546 ◀
oropharyngeal suction, A4628
starter set, A4329
 trachea (suction), A4609, A4610, A4624
transluminal angioplasty, C2623
transtracheal oxygen, A4608
vascular, A4300–A4301
Catheterization, specimen collection, P9612, P9615
CBC, G0306, G0307
Cefazolin sodium, J0689, J0690 ◀
Cefepime HCl, J0692, J0701, J0703 ◀
Cefiderocol, J0699
Cefotaxime sodium, J0698
Ceftaroline fosamil, J0712
Ceftazidime, J0713, J0714
Ceftizoxime sodium, J0715
Ceftolozane 50 mg and tazobactam 25 mg, J0695
Ceftriaxone sodium, J0696
Cefuroxime sodium, J0697
Celera, Q4259 ◀
CellCept, K0412
Cellesta cord, Q4214
Cellesta or cellesta duo, Q4184
Cellular therapy, M0075
Cement, ostomy, A4364
Cemiplimab injection-rwlc, J9119
Centrifuge, A4650
Centruroides Immune F(ab), J0716
Cephalin Floculation, blood, P2028
Cephalothin sodium, J1890
Cephapirin sodium, J0710
Certification, physician, home, health (per calendar month), G0179–G0182
Physician certification, home health, G0180
Physician recertification, home health, G0179
Physician supervision, home health, complex care, 30 min or more, G0181
Physician supervision, hospice 30 min or more, G0182
Certolizumab pegol, J0717
Cerumen, removal, G0268
Cervical
cancer, screening, G0101
cytopathology, G0123, G0124, G0141–G0148
screening, automated thin layer, manual rescreening, physician supervision, G0145
screening, automated thin layer preparation, cytotechnologist, physician interpretation,
G0143
 screening, automated thin layer preparation, physician supervision, G0144
screening, by cytotechnologist, physician supervision, G0123
screening, cytopathology smears, automated system, physician interpretation, G0141
screening, interpretation by physician, G0124
screening smears, automated system, manual rescreening, G0148
screening smears, automated system, physician supervision, G0147
halo, L0810–L0830
head harness/halter, E0942
orthosis, L0100–L0200
cervical collar molded to patient, L0170
cervical, flexible collar, L0120–L0130
cervical, multiple post collar, supports, L0180–L0200
cervical, semi-rigid collar, L0150–L0160, L0172, L0174
cranial cervical, L0112–L0113
traction, E0855, E0856
Cervical cap contraceptive, A4261
Cervical-thoracic-lumbar-sacral orthosis (CTLSO), L0700, L0710
Cetuximab, J9055
Chair
adjustable, dialysis, E1570
lift, E0627
rollabout, E1031
sitz bath, E0160–E0162
transport, E1035–E1039
chair, adult size, heavy duty, greater than 300 pounds, E1039
chair, adult size, up to 300 pounds, E1038
chair, pediatric, E1037
multi-positional patient transfer system, extra-wide, greater than 300 pounds, E1036
multi-positional patient transfer system, up to 300 pounds, E1035
Change ◀
ureterostomy tube, C7549 ◀
Chaplain Services, Q9001–Q9003 ◀
Chelation therapy, M0300
Chemical endarterectomy, M0300
Chemistry and toxicology tests, P2028–P3001
Chemotherapy
administration (hospital reporting only), Q0083–Q0085
drug, oral, not otherwise classified, J8999
drugs; (see also drug by name), J9000–J9999
Chest shell (cuirass), E0457
Chest Wall Oscillation System, E0483
 hose, replacement, A7026
vest, replacement, A7025
Chest wrap, E0459
Chin cup, cervical, L0150
Chloramphenicol sodium succinate, J0720
Chlordiazepoxide HCl, J1990
Chloromycetin sodium succinate, J0720
Chloroprocaine HCl, J2400,✖ J2401–J2402 ◀
Chloroquine HCl, J0390
Chlorothiazide sodium, J1205
Chlorpromazine HCl, J3230
Chlorpromazine HCL, 5 mg, oral, Q0161
Chorionic gonadotropin, J0725
Choroid, lesion, destruction, G0186
Chromic phosphate P32 suspension, A9564
Chromium CR-51 sodium chromate, A9553
Cidofovir, J0740
Cilastatin sodium, imipenem, J0743
Ciltacabtagene, Q2056 ◀
Cinacalcet, J0604
Ciprofloxacin
for intravenous infusion, J0744
octic suspension, J7342
Cisplatin, J9060
Cladribine, J9065
Clamp
dialysis, A4918
external urethral, A4356
Cleanser, wound, A6260
Cleansing agent, dialysis equipment, A4790
Clofarabine, J9027
Clonidine, J0735
Closure, wound, adhesive, tissue, G0168
Clotting time tube, A4771
Clubfoot wedge, L3380
Cocaine, C9143 ◀
Cochlear prosthetic implant, L8614
accessories, L8615–L8617, L8618
batteries, L8621–L8624
replacement, L8619, L8627–L8629
external controller component, L8628
 external speech processor and controller, integrated system, L8619
external speech processor, component, L8627
transmitting coil and cable, integrated, L8629
Cocoon, membrane, Q4264 ◀
Codeine phosphate, J0745
Cold/Heat, application, E0200–E0239
bilirubin light, E0202
electric heat pad, moist, E0215
electric heat pad, standard, E0210
heat lamp with stand, E0205
heat lamp, without stand, E0200
hydrocollator unit, E0225
hydrocollator unit, portable, E0239
infrared heating pad system, E0221
non-contact wound warming device, E0231
paraffin bath unit, E0235
pump for water circulating pad, E0236
therapeutic lightbox, E0203
warming card, non-contact wound warming device, E0232
water circulating cold pad, with pump, E0218
water circulating heat pad, with pump, E0217
Colistimethate sodium, J0770
Collagen
meniscus implant procedure, G0428
skin test, G0025
urinary tract implant, L8603
wound dressing, A2006–A2014, A6020–A6024 ◀
Collagenase, Clostridium histolyticum, J0775
Collar, cervical
multiple post, L0180–L0200
nonadjust (foam), L0120
Collection and preparation, saliva, D0417
Colorectal, screening, cancer, G0104–G0106, G0120–G0122, G0328
Coly-Mycin M, J0770
Comfort items, A9190
Commode, E0160–E0175
chair, E0170–E0171
lift, E0172, E0625
pail, E0167
seat, wheelchair, E0968
Complete, blood, count, G0306, G0307
Composite dressing, A6200–A6205
Compressed gas system, E0424–E0446
oximeter device, E0445
portable gaseous oxygen system, purchase, E0430
portable gaseous oxygen system, rental, E0431
portable liquid oxygen, rental, container/supplies, E0434
portable liquid oxygen, rental, home liquefier, E0433
portable liquid oxygen system, purchase, container/refill adapter, E0435
portable oxygen contents, gaseous, 1 month, E0443
portable oxygen contents, liquid, 1 month, E0444
stationary liquid oxygen system, purchase, use of reservoir, E0440
stationary liquid oxygen system, rental, container/supplies, E0439
stationary oxygen contents, gaseous, 1 month, E0441
stationary oxygen contents, liquid, 1 month, E0442
stationary purchase, compressed gas system, E0425
stationary rental, compressed gaseous oxygen system, E0424
topical oxygen delivery system, NOS, E0446
Compression
bandage, A4460
burn garment, A6501–A6512
stockings, A6530–A6549
Compressor, E0565, E0570, E0571, E0572, E0650–E0652, K1031–K1033 ◀
Conductive gel/paste, A4558
Conductivity meter, bath, dialysis, E1550
Conference, team, G0175, G9007, S0220, S0221
coordinate care fee, scheduled team conference, G9007
medical conference/physician/interdisciplinary team, patient present, 30 min, S0220
medical conference physician/interdisciplinary team, patient present, 60 min, S0221
scheduled interdisciplinary team conference, patient present, G0175
Congo red, blood, P2029
Consultation, S0285, S0311, T1040, T1041
dental, D9311
Telehealth, G0425–G0427
Contact layer, A6206–A6208
Contact lens, V2500–V2599
Continent device, A5081, A5082, A5083
Continuous glucose monitoring system
receiver, A9278, E2103, S1037 ◀
sensor, A9276, S1035
transmitter, A9277, S1036
Continuous passive motion exercise device, E0936
Continuous positive airway pressure device(CPAP), E0601
compressor, K0269
Contraceptive
cervical cap, A4261
condoms, A4267, A4268
diaphragm, A4266
intratubal occlusion device, A4264
intrauterine, copper, J7300
intrauterine, levonorgestrel releasing, J7296–J7298, J7301
patch, J7304
spermicide, A4269
supply, A4267–A4269
vaginal ring, J7303
Contracts, maintenance, ESRD, A4890
Contrast, Q9951–Q9969
HOCM, Q9958–Q9964
injection, iron based magnetic resonance, per ml, Q9953
injection, non-radioactive, non-contrast, visualization adjunct, Q9968
injection, octafluoropropane microspheres, per ml, Q9956
injection, perflexane lipid microspheres, per ml, Q9955
injection, perflutren lipid microspheres, per ml, Q9957
LOCM, Q9965–Q9967
LOCM, 400 or greater mg/ml iodine, per ml, Q9951
oral magnetic resonance contrast, Q9954
Tc-99m per study dose, Q9969
Contrast material
injection during MRI, A4643
low osmolar, A4644–A4646
Coordinated, care, G9001–G9011
CORF, registered nurse- face-face, G0128
Corneal tissue processing, V2785
Corset, spinal orthosis, L0970–L0976
LSO, corset front, L0972
LSO, full corset, L0976
TLSO, corset front, L0970
TLSO, full corset, L0974
Corticorelin ovine triflutate, J0795
Corticotropin, J0800
Corvert (see Ibutilide fumarate)
Cosyntropin, J0833, J0834
Cough stimulating device, A7020, E0482
Counseling
alcohol misuse, G0443
cardiovascular disease, G0448
control of dental disease, D1310, D1320
immunization, G0310–G0315 ◀
obesity, G0447
sexually transmitted infection, G0445
Count, blood, G0306, G0307
Counterpulsation, external, G0166
Cover, wound
alginate dressing, A6196–A6198
foam dressing, A6209–A6214
hydrogel dressing, A6242–A6248
non-contact wound warming cover, and accessory, A6000, E0231, E0232
specialty absorptive dressing, A6251–A6256
Covid test, K1034 ◀
CPAP (continuous positive airway pressure) device, E0601
headgear, K0185
humidifier, A7046
intermittent assist, E0452
Cradle, bed, E0280
Cranial electrotherapy stimulation (CES), K1002
Crib, E0300
Cromolyn sodium, inhalation solution, unit dose, J7631, J7632
Crotalidae polyvalent immune fab, J0840
Crowns, D2710–D2983, D4249, D6720–D6794
clinical crown lengthening-hard tissue, D4249
fixed partial denture retainers, crowns, D6710–D6794
single restoration, D2710–D2983
Crutches, E0110–E0118
accessories, A4635–A4637, K0102
crutch substitute, lower leg, E0118
forearm, E0110–E0111
underarm, E0112–E0117
Cryoprecipitate, each unit, P9012
CTLSO, L0700, L0710, L1000–L1120
addition, axilla sling, L1010
addition, cover for upright, each, L1120
addition, kyphosis pad, L1020
addition, kyphosis pad, floating, L1025
addition, lumbar bolster pad, L1030
 addition, lumbar rib pad, L1040
addition, lumbar sling, L1090
addition, outrigger, L1080
addition, outrigger bilateral, vertical extensions, L1085
addition, ring flange, L1100
addition, ring flange, molded to patient model, L1110
addition, sternal pad, L1050
addition, thoracic pad, L1060
addition, trapezius sling, L1070
anterior-posterior-lateral control, molded to patient model (CTLSO), L0710
cervical, thoracic, lumbar, sacral orthrosis (CTLSO), L0700
furnishing initial orthrosis, L1000
immobilizer, infant size, L1001
tension based scoliosis orthosis, fitting, L1005
Cuirass, E0457
Culture sensitivity study, P7001
Cushion, wheelchair, E0977
Cutaquig, J1551 ◀
Cyanocobalamin Cobalt C057, A9559
Cycler dialysis machine, E1594
Cyclophosphamide, J9070, J9071 ◀
oral, J8530
Cyclosporine, J7502, J7515, J7516
Cygnus matrix, Q4199
Cystourethroscopy, C7550, C7554 ◀
Cytarabine, J9100
liposome, J9098
Cytomegalovirus immune globulin (human), J0850
Cytopathology, cervical or vaginal, G0123, G0124, G0141–G0148
 D
Dacarbazine, J9130
Daclizumab, J7513
Dactinomycin, J9120
Dalalone, J1100
Dalbavancin, 5mg, J0875
Dalteparin sodium, J1645
Daptomycin, J0877, J0878 ◀
Daratumumab, J9144, J9145
Darbepoetin Alfa, J0881–J0882
Daunorubicin
Citrate, J9151
HCl, J9150
DaunoXome (see Daunorubicin citrate)
Debridement
bone, C7500 ◀
Decitabine, J0893, J0894 ◀
Decubitus care equipment, E0180–E0199
air fluidized bed, E0194
air pressure mattress, E0186
air pressure pad, standard mattress, E0197
dry pressure mattress, E0184
dry pressure pad, standard mattress, E0199
gel or gel-like pressure pad mattress, standard, E0185
gel pressure mattress, E0196
heel or elbow protector, E0191
positioning cushion, E0190
power pressure reducing mattress overlay, with pump, E0181, E0183 ◀
powered air flotation bed, E0193
pump, alternating pressure pad, replacement, E0182
synthetic sheepskin pad, E0189
water pressure mattress, E0187
water pressure pad, standard mattress, E0198
Deferoxamine mesylate, J0895
Defibrillator, external, E0617, K0606
battery, K0607
electrode, K0609
garment, K0608
Degarelix, J9155
Deionizer, water purification system, E1615
Delivery/set-up/dispensing, A9901
Denileukin diftitox, J9160
Denosumab, J0897
Density, bone, study, G0130
Dental procedures
adjunctive general services, D9110–D9999
alveoloplasty, D7310–D7321
analgesia, D9230
diagnostic, D0120–D0999
endodontics, D3000–D3999
evaluations, D0120–D0180
implant services, D6000–D6199
implants, D3460, D5925, D6010–D6067, D6075–D6199
laboratory, D0415–D0999
maxillofacial, D5900–D5999
orthodontics, D8000–D8999
periodontics, D4000–D4999
preventive, D1000–D1999
prosthetics, D5911–D5960, D5999
prosthodontics, fixed, D6200–D6999
prosthodontics, removable, D5000–D5999
restorative, D2000–D2999
scaling, D4341–D4346, D6081
Dentures, D5110–D5899
Depo-estradiol cypionate, J1000
Dermacell, dermacell awn or dermacell awn porous, Q4122
Dermal filler injection, G0429
Desmopressin acetate, J2597
Destruction, lesion, choroid, G0186
Detector, blood leak, dialysis, E1560
Developmental testing, G0451
Devices, other orthopedic, E1800–E1841
assistive listening device, V5267–V5290
Dexamethasone
acetate, J1094
inhalation solution, concentrated, J7637
inhalation solution, unit dose, J7638
intravitreal implant, J7312
lacrimal ophthalmic insert, J1096
 oral, J8540
sodium phosphate, J1100
Dextran, J7100
Dextrose
saline (normal), J7042
water, J7060, J7070
Dextrose, 5% in lactated ringers infusion, J7121
Dextrostick, A4772
Diabetes
evaluation, G0245, G0246
shoes (fitting/modifications), A5500–A5508
deluxe feature, depth-inlay shoe, A5508
depth inlay shoe, A5500
molded from cast patient’s foot, A5501
shoe with metatarsal bar, A5505
shoe with off-set heel(s), A5506
shoe with rocker or rigid-bottom rocker, A5503
shoe with wedge(s), A5504
specified modification NOS, depth-inlay shoe, A5507
training, outpatient, G0108, G0109
Diagnostic
dental services, D0100–D0999
copper, A9592
florbetaben, Q9983
flutemetamol F18, Q9982
mammography, digital image, G9899, G9900
radiology services, R0070–R0076
Dialysate
concentrate additives, A4765
solution, A4720–A4728
testing solution, A4760
Dialysis
air bubble detector, E1530
bath conductivity, meter, E1550
chemicals/antiseptics solution, A4674
circuit, C7513–C7515, C7530 ◀
disposable cycler set, A4671
emergency, G0257
equipment, E1510–E1702
extension line, A4672–A4673
filter, A4680
 fluid barrier, E1575
home, S9335, S9339
kit, A4820
pressure alarm, E1540
shunt, A4740
supplies, A4650–A4927
tablo hemodialysis system, E1629
tourniquet, A4929
unipuncture control system, E1580
unscheduled, G0257
venous pressure clamp, A4918
Dialyzer, A4690
Diaper, T1500, T4521–T4540, T4543, T4544
adult incontinence garment, A4520, A4553
incontinence supply, rectal insert, any type, each, A4337
disposable penile wrap, T4545
Diathermy low frequency ultrasonic treatment device for home use, K1004
Diazepam, J3360
Diazoxide, J1730
Diclofenac, J1130
Dicyclomine HCl, J0500
Diethylstilbestrol diphosphate, J9165
Difelikefalin (for ESRD on dialysis), J0879 ◀
Digital behavioral therapy, A9291 ◀
Digoxin, J1160
Digoxin immune fab (ovine), J1162
Dihydroergotamine mesylate, J1110
Dimenhydrinate, J1240
Dimercaprol, J0470
Dimethyl sulfoxide (DMSO), J1212
Diphenhydramine HCl, J1200
Dipyridamole, J1245
Disarticulation
lower extremities, prosthesis, L5000–L5999
above knee, L5200–L5230
additions exoskeletal-knee-shin system, L5710–L5782
additions to lower extremities, L5610–L5617
additions to socket insert, L5654–L5699
additions to socket variations, L5630–L5653
additions to test sockets, L5618–L5629
additions/replacements, feet-ankle units, L5700–L5707
 ankle, L5050–L5060
below knee, L5100–L5105
component modification, L5785–L5795
endoskeletal, L5810–L5999
endoskeletal, above knee, L5321
endoskeletal, hip disarticulation, L5331–L5341
endoskeleton, below knee, L5301–L5312
hemipelvectomy, L5280
hip disarticulation, L5250–L5270
immediate postsurgical fitting, L5400–L5460
initial prosthesis, L5500–L5505
knee disarticulation, L5150–L5160
partial foot, L5000–L5020
preparatory prosthesis, L5510–L5600
upper extremities, prosthesis, L6000–L6692
above elbow, L6250
additions to upper limb, L6600–L6698
below elbow, L6100–L6130
elbow disarticulation, L6200–L6205
endoskeletal, below elbow, L6400
endoskeletal, interscapular thoracic, L6570–L6590
endoskeletal, shoulder disarticulation, L6550
immediate postsurgical procedures, L6380–L6388
interscapular/thoracic, L6350–L6370
partial hand, L6000–L6026
shoulder disarticulation, L6300–L6320
wrist disarticulation, L6050–L6055
Disease
status, oncology, G9063–G9139
Dispensing, fee, pharmacy, G0333, Q0510–Q0514, S9430
dispensing fee inhalation drug(s), 30 days, Q0513
dispensing fee inhalation drug(s), 90 days, Q0514
inhalation drugs, 30 days, as a beneficiary, G0333
initial immunosuppressive drug(s), post transplanr, G0510
oral anti-cancer, oral anti-emetic, immunosuppressive, first prescription, Q0511
oral anti-cancer, oral anti-emetic, immunosuppressive, subsequent preparation, Q0512
Disposable collection and storage bag for breast milk, K1005
Disposable supplies, ambulance, A0382, A0384, A0392–A0398
DME
miscellaneous, A9900–A9999
DME delivery, set up, A9901
 DME supple, NOS, A9999
DME supplies, A9900
DMSO, J1212
Dobutamine HCl, J1250
Docetaxel, J9171
Documentation
antidepressant, G8126–G8128
blood pressure, G8476–G8478
bypass, graft, coronary, artery, documentation, G8160–G8163
CABG, G8160–G8163
dysphagia, G8232
dysphagia, screening, G8232, V5364
ECG, 12–lead, G8705, G8706
eye, functions, G8315–G8333
influenza, immunization, G8482–G8484, M1169 ◀
kidney health evaluation, M1189–M1190 ◀
medical reason, M1178, M1183–M1185, M1194, M1201–M1202 ◀
pharmacologic therapy for osteoporosis, G8635
physician for DME, G0454
prophylactic antibiotic, G8702, G8703
prophylactic parenteral antibiotic, G8629–G8632
prophylaxis, DVT, G8218
prophylaxis, thrombosis, deep, vein, G8218
urinary, incontinence, G8063, G8267
vaccine, immunization, M1172 ◀
Dolasetron mesylate, J1260
Dome and mouthpiece (for nebulizer), A7016
Dopamine HCl, J1265
Doripenem, J1267
Dornase alpha, inhalation solution, unit dose form, J7639
Dostarlimab-gxly, J9272 ◀
Doxercalciferol, J1270
Doxil, J9001
Doxorubicin HCl, J9000, J9002
Drainage
bag, A4357, A4358
board, postural, E0606
bottle, A5102
Dressing
alginate, A6196–A6199
collagen, A6020–A6024
 composite, A6200–A6205
contact layer, A6206–A6208
foam, A6209–A6215
gauze, A6216–A6230, A6402–A6406
holder/binder, A4462
hydrocolloid, A6234–A6241
hydrogel, A6242–A6248
specialty absorptive, A6251–A6256
transparent film, A6257–A6259
tubular, A6457
wound, K0744–K0746
Droperidol, J1790
and fentanyl citrate, J1810
Dropper, A4649
Drugs; (see also Table of Drugs)
administered through a metered dose inhaler, J3535
antiemetic, J8498, J8597, Q0163–Q0181
chemotherapy, J8500–J9999
disposable delivery system, 50 ml or greater per hour, A4305
disposable delivery system, 5 ml or less per hour, A4306
immunosuppressive, J7500–J7599
infusion supplies, A4221, A4222, A4230–A4232
inhalation solutions, J7608–J7699
non-prescription, A9150
not otherwise classified, J3490, J7599, J7699, J7799, J7999, J8499, J8999, J9999
oral, NOS, J8499
prescription, oral, J8499, J8999
Dry pressure pad/mattress, E0179, E0184, E0199
Duel layer impax membrane, Q4262 ◀
Durable medical equipment (DME), E0100–E1830, K Codes
additional oxygen related equipment, E1352–E1406
arm support, wheelchair, E2626–E2633
artificial kidney machines/accessories, E1500–E1699
attachments, E0156–E0159
bath and toilet aides, E0240–E0249
canes, E0100–E0105
commodes, E0160–E0175
crutches, E0110–E0118
decubitus care equipment, E0181–E0199
DME, respiratory, inexpensive, purchased, A7000–A7509
gait trainer, E8000–E8002
 heat/cold application, E0200–E0239
hospital beds and accessories, E0250–E0373
humidifiers/nebulizers/compressors, oxygen IPPB, E0550–E0585
infusion supplies, E0776–E0791
IPPB machines, E0500
jaw motion rehabilitation system, E1700–E1702
miscellaneous, E1902–E2120
monitoring equipment, home glucose, E0607
negative pressure, E2402
other orthopedic devices, E1800–E1841
oxygen/respiratory equipment, E0424–E0487
pacemaker monitor, E0610–E0620
patient lifts, E0621–E0642
pneumatic compressor, E0650–E0676
rollout chair/transfer system, E1031–E1039
safety equipment, E0700–E0705
speech device, E2500–E2599
suction pump/room vaporizers, E0600–E0606
temporary DME codes, regional carriers, K0000–K9999
TENS/stimulation device(s), E0720–E0770
traction equipment, E0830–E0900
trapeze equipment, fracture frame, E0910–E0948
walkers, E0130–E0155
wheelchair accessories, E2201–E2397
wheelchair, accessories, E0950–E1030
wheelchair, amputee, E1170–E1200
wheelchair cusion/protection, E2601–E2621
wheelchair, fully reclining, E1050–E1093
wheelchair, heavy duty, E1280–E1298
wheelchair, lightweight, E1240–E1270
wheelchair, semi-reclining, E1100–E1110
wheelchair, skin protection, E2622–E2625
wheelchair, special size, E1220–E1239
wheelchair, standard, E1130–E1161
whirlpool equipment, E1300–E1310
Duraclon, (see Clonidine)
Dyphylline, J1180
Dysphagia, screening, documentation, G8232, V5364
Dystrophic, nails, trimming, G0127
 E
Ear mold, V5264, V5265
Ecallantide, J1290
Echocardiography injectable contrast material, A9700
ECG, 12–lead, G8704
Eculizumab, J1300
ED, visit, G0380–G0384
Edetate
calcium disodium, J0600
disodium, J3520
Educational Services
chronic kidney disease, G0420, G0421
Efgartigimod, J9332 ◀
Eggcrate dry pressure pad/mattress, E0184, E0199
EKG, G0403–G0405
Elbow
disarticulation, endoskeletal, L6450
orthosis (EO), E1800, L3700–L3740, L3760, L3671
dynamic adjustable elbow flexion device, E1800
elbow arthrosis, L3702–L3766
protector, E0191
Electric hand, L7007–L7008
Electric, nerve, stimulator, transcutaneous, A4595, E0720–E0749
conductive garment, E0731
electric joint stimulation device, E0762
electrical stimulator supplies, A4595, A4596 ◀
electromagnetic wound treatment device, E0769
electronic salivary reflex stimulator, E0755
EMG, biofeedback device, E0746
functional electrical stimulator, nerve and/or muscle groups, E0770
functional stimulator sequential muscle groups, E0764
incontinence treatment system, E0740
nerve stimulator (FDA), treatment nausea and vomiting, E0765
osteogenesis stimulator, electrical, surgically implanted, E0749
osteogenesis stimulator, low-intensity ultrasound, E0760
osteogenesis stimulator, non-invasive, not spinal, E0747
osteogenesis stimulator, non-invasive, spinal, E0748
radiowaves, non-thermal, high frequency, E0761
stimulator, electrical shock unit, E0745
 stimulator for scoliosis, E0744
TENS, four or more leads, E0730
TENS, two lead, E0720
Electrical stimulation device used for cancer treatment, E0766
Electrical work, dialysis equipment, A4870
Electrodes, per pair, A4555, A4556
Electromagnetic, therapy, G0295, G0329
Electronic medication compliance, T1505
Electronic positional obstructive sleep apnea treatment, K1001
Elevating leg rest, K0195
Elliotts B solution, J9175
Elotuzumab, J9176
Emapalumab injection-lzsg, J9210
Emergency department, visit, G0380–G0384
EMG, E0746
Eminase, J0350
Encephalitis, due to vaccine, M1162 ◀
Endarterectomy, chemical, M0300
Endodontic procedures, D3000–D3999
periapical services, D3410–D3470
pulp capping, D3110, D3120
root canal therapy, D3310–D3353
therapy, D3310–D3330
Endodontics, dental, D3000–D3999
Endoscope sheath, A4270
Endoscopic
retrograde cholangiopancreatography, C7541–C7544 ◀
Endoskeletal system, addition, L5848, L5856–L5857, L5925, L5961, L5969
Enema, bag, A4458
Enfuvirtide, J1324
Enoxaparin sodium, J1650
Enteral
feeding supply kit (syringe) (pump) (gravity), B4034–B4036
formulae, B4149–B4156, B4157–B4162
nutrition infusion pump (with alarm) (without), B9000, B9002
therapy, supplies, B4000–B9999
enteral and parenteral pumps, B9002–B9999
enteral formula/medical supplies, B0434–B4162
parenteral solutions/supplies, B4164–B5200
Epinephrine, J0171, J0173 ◀
Epirubicin HCl, J9178
Epoetin alpha, J0885, Q4081
Epoetin alpha-epbx, Retacrit (for ESRD on dialysis), Q5105
Epoetin alpha-epbx, Retacrit (non-ESRD use), Q5106
Epoetin beta, J0887–J0888
Epoprostenol, J1325
Eptinezumab-jjmr, J3032
Equipment
decubitus, E0181–E0199
exercise, A9300, E0935, E0936
orthopedic, E0910–E0948, E1800–E8002
oxygen, E0424–E0486, E1353–E1406
pump, E0781, E0784, E0791
respiratory, E0424–E0601
safety, E0700, E0705
traction, E0830–E0900
transfer, E0705
trapeze, E0910–E0912, E0940
whirlpool, E1300, E1310
Eravacycline injection, J0122
Erection device, tension ring, L7902
Ergonovine maleate, J1330
Eribulin mesylate, J9179
Ertapenem sodium, J1335
Erythromycin lactobionate, J1364
Esketamine, nasal spray, S0013
ESRD (End-Stage Renal Disease); (see also Dialysis)
diagnosis of, M1187 ◀
machines and accessories, E1500–E1699
adjustable chair, ESRD, E1570
centrifuge, dialysis, E1500
dialysis equipment, NOS, E1699
hemodialysis, air bubble detector, replacement, E1530
hemodialysis, bath conductivity meter, E1550
hemodialysis, blood leak detector, replacement, E1560
hemodialysis, blood pump, replacement, E1620
hemodialysis equipment, delivery/installation charges, E1600
hemodialysis, heparin infusion pump, E1520
hemodialysis machine, E1590
hemodialysis, portable travel hemodialyzer system, E1635
hemodialysis, pressure alarm, E1540
hemodialysis, reverse osmosis water system, E1615
 hemodialysis, sorbent cartridges, E1636
hemodialysis, transducer protectors, E1575
hemodialysis, unipuncture control system, E1580
hemodialysis, water softening system, E1625
hemostats, E1637
peritoneal dialysis, automatic intermittent system, E1592
peritoneal dialysis clamps, E1634
peritoneal dialysis, cycler dialysis machine, E1594
peritoneal dialysis, reciprocating system, E1630
scale, E1639
wearable artificial kidney, E1632
plumbing, A4870
supplies, A4651–A4929
acetate concentrate solution, hemodialysis, A4708
acid concentrate solution, hemodialysis, A4709
activated carbon filters, hemodialysis, A4680
ammonia test strip, dialysis, A4774
automatic blood pressure monitor, A4670
bicarbonate concentrate, powder, hemodialysis, A4707
bicarbonate concentrate, solution, A4706
blood collection tube, vaccum, dialysis, A4770
blood glucose test strip, dialysis, A4772
blood pressure cuff only, A4663
blood tubing, arterial and venous, hemodialysis, A4755
blood tubing, arterial or venous, hemodialysis, A4750
chemicals/antiseptics solution, clean dialysis equipment, A4674
dialysate solution, non-dextrose, A4728
dialysate solution, peritoneal dialysis, A4720–A4726, A4760–A4766
dialyzers, hemodialysis, A4690
disposable catheter tips, peritoneal dialysis, A4860
disposable cycler set, dialysis machine, A4671
drainage extension line, dialysis, sterile, A4672
extension line easy lock connectors, dialysis, A4673
fistula cannulation set, hemodialysis, A4730
injectable anesthetic, dialysis, A4737
occult blood test strips, dialysis, A4773
peritoneal dialysis, catheter anchoring device, A4653
protamine sulfate, hemodialysis, A4802
serum clotting timetube, dialysis, A4771
shunt accessory, hemodialysis, A4740
sphygmomanometer, cuff and stethoscope, A4660
 syringes, A4657
topical anesthetic, dialysis, A4736
treated water, peritoneal dialysis, A4714
“Y set” tubing, peritoneal dialysis, A4719
Estrogen conjugated, J1410
Estrone (5, Aqueous), J1435
Etelcalcetide, J0606
Eteplirsen, J1428
Ethanolamine oleate, J1430
Etidronate disodium, J1436
Etonogestrel implant system, J7307
Etoposide, J9181
oral, J8560
Euflexxa, J7323
Evaluation
conformity, V5020
contact lens, S0592
dental, D0120–D0180
diabetic, G0245, G0246
footwear, G8410–G8416
hearing, S0618, V5008, V5010
hospice, G0337
multidisciplinary, H2000
nursing, T1001
ocularist, S9150
performance measurement, S3005
resident, T2011
speech, S9152
team, T1024
Everolimus, J7527
Evinacumab-dgnb J1305
Examination
gynecological, S0610–S0613
ophthalmological, S0620, S0621
oral, D0120–D0160
pinworm, Q0113
Excision ◀
cervical nodes, C7503 ◀
neuroma, C7551 ◀
Exercise
class, S9451
 equipment, A9300
External
ambulatory infusion pump, E0781, E0784
ambulatory infusion pump continuous glucose sensing, E0787
ambulatory insulin delivery system, A9274
power, battery components, L7360–L7368
power, elbow, L7160–L7191
urinary supplies, A4356–A4359
Extractions; (see also Dental procedures), D7111–D7140, D7251
Extremity
belt/harness, E0945
traction, E0870–E0880
Eye
case, V2756
functions, documentation, G8315–G8333
lens (contact) (spectacle), V2100–V2615
pad, patch, A6410–A6412
prosthetic, V2623, V2629
service (miscellaneous), V2700–V2799
stent, S1091

F
Face tent, oxygen, A4619
Faceplate, ostomy, A4361
Facility services, dental, G0330 ◀
Factor IX, J7193, J7194, J7195, J7200–J7202
Factor VIIA coagulation factor, recombinant, J7189, J7205, J7212
Factor VIII, anti-hemophilic factor, J7182, J7185, J7190–J7192, J7207–J7209
Factor X, J7175
Factor XIII, anti-hemophilic factor, J7180, J7188
Factor XIII, A-subunit, J7181
Family Planning Education, H1010
Faricimab-svoa, J2777 ◀
Fee
coordinated care, G9001–G9011
dispensing, pharmacy, G0333, Q0510–Q0514, S9430
Fentanyl citrate, J3010
and droperidol, J1810
Fern test, Q0114
Ferric derisomaltose, J1437
Ferric pyrophosphate citrate powder, J1444
Ferumoxytol, Q0138, Q0139
Filgrastim (G-CSF &amp; TBO), J1442, J1447, Q5101
Filler, wound
alginate dressing, A6199
foam dressing, A6215
hydrocolloid dressing, A6240, A6241
hydrogel dressing, A6248
not elsewhere classified, A6261, A6262
Film, transparent (for dressing), A6257–A6259
Filter
aerosol compressor, A7014
dialysis carbon, A4680
ostomy, A4368
tracheostoma, A4481
ultrasonic generator, A7014
Fistula cannulation set, A4730
Flebogamma, J1572
Florbetapir F18, A9586
Flortaucipir, A9601 ◀
Flowmeter, E0440, E0555, E0580
Floxuridine, J9200
Fluconazole, injection, J1450
Fludarabine phosphate, J8562, J9185
Fluid barrier, dialysis, E1575
Fluid flow, Q4206
Flunisolide inhalation solution, J7641
Fluocinolone, J7311, J7313
(Yutiq), J7314
Fluoride treatment, D1201–D1205
Fluorodeoxyglucose F-18 FDG, A9552
Fluorodopa, A9602 ◀
Fluoroestradiol F 18, A9591
Fluorouracil, J9190
Fluphenazine decanoate, J2680
Foam
dressing, A6209–A6215
pad adhesive, A5126
Folding walker, E0135, E0143
Foley catheter, A4312–A4316, A4338–A4346
 indwelling catheter, specialty type, A4340
indwelling catheter, three-way, continuous irrigation, A4346
indwelling catheter, two-way, all silicone, A4344
indwelling catheter, two-way latex, A4338
insertion tray with drainage bag, A4312
insertion tray with drainage bag, three-way, continuous irrigation, A4316
insertion tray with drainage bag, two-way latex, A4314
insertion tray with drainage bag, two-way, silicone, A4315
insertion tray without drainage bag, A4313
Fomepizole, J1451
Fomivirsen sodium intraocular, J1452
Fondaparinux sodium, J1652
Foot care, G0247
Footdrop splint, L4398
Footplate, E0175, E0970, L3031
Footwear, orthopedic, L3201–L3265
additional charge for split size, L3257
Benesch boot, pair, child, L3213
Benesch boot, pair, infant, L3212
Benesch boot, pair, junior, L3214
custom molded shoe, prosthetic shoe, L3250
custom shoe, depth inlay, L3230
ladies’ shoe, depth inlay, L3216
ladies’ shoe, hightop, L3217
ladies’ shoe, oxford, L3215
ladies’ shoe, oxford/brace, L3224
men’s shoe, depth inlay, L3221
men’s shoe, hightop, L3222
men’s shoe, oxford, L3219
men’s shoe, oxford/brace, L3225
molded shoe, custom fitted, Plastazote, L3253
non-standard size or length, L3255
non-standard size or width, L3254
Plastazote sandal, L3265
shoe, hightop, child, L3206
shoe, hightop, infant, L3204
shoe, hightop, junior, L3207
shoe molded/patient model, Plastazote, L3252
shoe, molded/patient model, silicone, L3251
shoe, oxford, child, L3202
shoe, oxford, infant, L3201
 shoe, oxford, junior, L3203
surgical boot, child, L3209
surgical boot, infant, L3208
surgical boot, junior, L3211
surgical boot/shoe, L3260
Forearm crutches, E0110, E0111
Formoterol, J7640
fumarate, J7606
Fosaprepitant, J1453, J1456 ◀
Foscarnet sodium, J1455
Fosphenytoin, Q2009
Fracture
bedpan, E0276
frame, E0920, E0930, E0946–E0948
attached to bed/weights, E0920
attachments for complex cervical traction, E0948
attachments for complex pelvic traction, E0947
dual, cross bars, attached to bed, E0946
free standing/weights, E0930
orthosis, L2106–L2136, L3980–L3984
ankle/foot orthosis, fracture, L2106–L2128
KAFO, fracture orthosis, L2132–L2136
upper extremity, fracture orthosis, L3980–L3984
orthotic additions, L2180–L2192, L3995
addition to upper extremity orthosis, sock, fracture, L3995
additions lower extremity fracture, L2180–L2192
Fragmin, (see Dalteparin sodium), J1645
Frames (spectacles), V2020, V2025
deluxe frame, V2025
purchases, V2020
Fremanezumab-vfrm, J3031
Fulvestrant, J9393–J9395 ◀
Furosemide, J1940
Fusion ◀
finger joints, C7506 ◀

G
Gadobutrol, A9585
Gadofosveset trisodium, A9583
Gadoxetate disodium, A9581
Gait trainer, E8000–E8002
Gallium Ga67, A9556
Gallium illuccix, A9596 ◀
Gallium locametz, A9800 ◀
Gallium nitrate, J1457
Galsulfase, J1458
Gamma globulin, J1460, J1560
injection, gamma globulin (IM), 1cc, J1460
injection, gamma globulin (IM), over 10cc, J1560
Gammagard liquid, J1569
Gammaplex, J1557
Gamunex, J1561
Ganciclovir
implant, J7310
sodium, J1570, J1574 ◀
Garamycin, J1580
Gas system
compressed, E0424, E0425
gaseous, E0430, E0431, E0441, E0443
liquid, E0434–E0440, E0442, E0444
Gastric freezing, hypothermia, M0100
Gatifloxacin, J1590
Gauze
impregnated, A6222–A6233, A6266
non-impregnated, A6402–A6404
Gefitinib, J8565
Gel
conductive, A4558
pressure pad, E0185, E0196
Gemcitabine HCl, not otherwise specified, J9201
Infugem, J9198
Gemtuzumab ozogamicin, J9203
Generator
neurostimulator (implantable), high frequency, C1822
neurostimulator (implantable), non-rechargeable, C1827 ◀
neurostimulator (implantable), rechargeable, C1826 ◀
ultrasonic with nebulizer, E0574–E0575
Gentamicin (Sulfate), J1580
Gingival procedures, D4210–D4240
gingival flap procedure, D4240–D4241
 gingivectomy or gingivoplasty, D4210–D4212
Glasses
air conduction, V5070
binaural, V5120–V5150
behind the ear, V5140
body, V5120
glasses, V5150
in the ear, V5130
bone conduction, V5080
frames, V2020, V2025
hearing aid, V5230
Glaucoma
screening, G0117, G0118
Gloves, A4927
Glucagon HCl, J1610, J1611 ◀
Glucose
monitor includes all supplies, K0553 ✖
monitor with integrated lancing/blood sample collection, E2101
monitor with integrated voice synthesizer, E2100
receiver (monitor) dedicated, K0554 ✖
test strips, A4253, A4772
Gluteal pad, L2650
Glycopyrrolate, inhalation solution, concentrated, J7642
Glycopyrrolate, inhalation solution, unit dose, J7643
Gold
foil dental restoration, D2410–D2430
gold foil, one surface, D2410
gold foil, two surfaces, D2420
gold foil, three surfaces, D2430
sodium thiomalate, J1600
Golimumab, J1602
Gomco drain bottle, A4912
Gonadorelin HCl, J1620
Goserelin acetate implant; (see also Implant), J9202
Grab bar, trapeze, E0910, E0940
Grade-aid, wheelchair, E0974
Gradient, compression stockings, A6530–A6549
below knee, 18–30 mmHg, A6530
below knee, 30–40 mmHg, A6531
below knee, thigh length, 18–30 mmHg, A6533
full length/chap style, 18–30 mmHg, A6536
 full length/chap style, 30–40 mmHg, A6537
full length/chap style, 40–50 mmHg, A6538
garter belt, A6544
non-elastic below knee, 30–50 mmhg, A6545
sleeve, NOS, A6549
thigh length, 30–40 mmHg, A6534
thigh length, 40–50 mmHg, A6535
waist length, 18–30 mmHg, A6539
waist length, 30–40 mmHg, A6540
waist length, 40–50 mmHg, A6541
Granisetron HCl, J1626
XR, J1627
Gravity traction device, E0941
Gravlee jet washer, A4470
Guidelines, practice, oncology, G9056–G9062

H
Habilitation, prevocational, waiver, T2047
Hair analysis (excluding arsenic), P2031
Halaven, Injection, eribulin mesylate, 0.1 mg, J9179
Hallus-Valgus dynamic splint, L3100
Hallux prosthetic implant, L8642
Halo procedures, L0810–L0860
addition HALO procedure, MRI compatible systems, L0859
addition HALO procedure, replacement liner, L0861
cervical halo/jacket vest, L0810
cervical halo/Milwaukee type orthosis, L0830
cervical halo/plaster body jacket, L0820
Haloperidol, J1630
decanoate, J1631
Halter, cervical head, E0942
Hand finger orthosis, prefabricated, L3923
Hand restoration, L6900–L6915
orthosis (WHFO), E1805, E1825, L3800–L3805, L3900–L3954
partial prosthesis, L6000–L6020
partial hand, little and/or ring finger remaining, L6010
partial hand, no finger, L6020
partial hand, thumb remaining, L6000
transcarpal/metacarpal or partial hand disarticulation prosthesis, L6025
rims, wheelchair, E0967
Handgrip (cane, crutch, walker), A4636
Harness, E0942, E0944, E0945
Headgear (for positive airway pressure device), K0185
Hearing
aid, V5030–V5267, V5298
aid-body worn, V5100
assistive listening device, V5268–V5274, V5281–V5290
battery, use in hearing device, V5266
contralateral routing, V5171–V5172, V5181, V5211–V5115, V5221
dispensing fee, binaural, V5160
dispensing fee, monaural hearing aid, any type, V5241
dispensing fee, unspecified hearing aid, V5090
ear impression, each, V5275
ear mold/insert, disposable, any type, V5265
ear mold/insert, not disposable, V5264
glasses, air conduction, V5070
glasses, bone conduction, V5080
hearing aid, analog, binaural, CIC, V5248
hearing aid, analog, binaural, ITC, V5249
hearing aid, analog, monaural, CIC, V5242
hearing aid, analog, monaural, ITC, V5243
hearing aid, BICROS, V5210–V5240
hearing aid, binaural, V5120–V5150
hearing aid, CROS, V5170–V5200
hearing aid, digital, V5254–V5261
hearing aid, digitally programmable, V5244–V5247, V5250–V5253
hearing aid, disposable, any type, binaural, V5263
hearing aid, disposable, any type, monaural, V5262
hearing aid, monaural, V5030–V5060
hearing aid, NOC, V5298
hearing aid or assistive listening device/supplies/accessories, NOS, V5267
hearing service, miscellaneous, V5299
semi-implantable, middle ear, V5095
assessment, S0618, V5008, V5010
devices, L8614, V5000–V5169, V5171–V5179, V5181–V5209, V5211–V5219,
V5221–V5299
services, V5000–V5999
Heat
application, E0200–E0239
infrared heating pad system, A4639, E0221
lamp, E0200, E0205
 pad, A9273, E0210, E0215, E0237, E0249
Heater (nebulizer), E1372
Heavy duty, wheelchair, E1280–E1298, K0006, K0007, K0801–K0886
detachable arms, elevating legrests, E1280
detachable arms, swing away detachable footrest, E1290
extra heavy duty wheelchair, K0007
fixed full length arms, elevating legrest, E1295
fixed full length arms, swing away detachable footrest, E1285
heavy duty wheelchair, K0006
power mobility device, not coded by DME PDAC or no criteria, K0900
power operated vehicle, group 2, K0806–K0808
power operated vehicle, NOC, K0812
power wheelchair, group 1, K0813–K0816
power wheelchair, group 2, K0820–K0843
power wheelchair, group 3, K0848–K0864
power wheelchair, group 4, K0868–K0886
power wheelchair, group 5, pediatric, K0890–K0891
power wheelchair, NOC, K0898
power-operated vehicle, group 1, K0800–K0802
special wheelchair seat depth and/or width, by construction, E1298
special wheelchair seat depth, by upholstery, E1297
special wheelchair seat height from floor, E1296
Heel
elevator, air, E0370
protector, E0191
shoe, L3430–L3485
stabilizer, L3170
Helicopter, ambulance; (see also Ambulance)
Helmet
cervical, L0100, L0110
head, A8000–A8004
Hemin, J1640
Hemipelvectomy prosthesis, L5280
Hemi-wheelchair, E1083–E1086
Hemodialysis machine, E1590
Hemodialyzer, portable, E1635
Hemofil M, J7190
Hemophilia clotting factor, J7190–J7198
anti-inhibitor, per IU, J7198
anti-thrombin III, human, per IU, J7197
Factor IX, complex, per IU, J7194
 Factor IX, purified, non-recombinant, per IU, J7193
Factor IX, recombinant, J7195
Factor VIII, human, per IU, J7190
Factor VIII, porcine, per IU, J7191
Factor VIII, recombinant, per IU, NOS, J7192
injection, antithrombin recombinant, 50 i.u., J7196
NOC, J7199
Hemostats, A4850, E1637
Hemostix, A4773
Hepagam B
IM, J1571
IV, J1573
Heparin
infusion pump, dialysis, E1520
lock flush, J1642
sodium, J1643, J1644 ◀
Hepatitis B, vaccine, administration, G0010
Hep-Lock (U/P), J1642
Hexalite, A4590
High osmolar contrast material, Q9958–Q9964
HOCM, 400 or greater mg/ml iodine, Q9964
HOCM, 150–199 mg/ml iodine, Q9959
HOCM, 200–249 mg/ml iodine, Q9960
HOCM, 250–299 mg/ml iodine, Q9961
HOCM, 300–349 mg/ml iodine, Q9962
HOCM, 350–399 mg/ml iodine, Q9963
HOCM, up to 149 mg/ml iodine, Q9958
Hip
disarticulation prosthesis, L5250, L5270
orthosis (HO), L1600–L1690
Hip-knee-ankle-foot orthosis (HKAFO), L2040–L2090
Histrelin
acetate, J1675
implant, J9225
HKAFO, L2040–L2090
Home
certification, home health, G0180
glucose, monitor, E0607, E2100, E2101, S1030, S1031
health, aide, G0156, S9122, T1021
health, aide, in home, per hour, S9122
health, aide, per visit, T1021
 health, clinical, social worker, G0155
health, data collection, G0322 ◀
health, hospice, each 15 min, G0156
health, occupational, therapist, G0152
health, physical therapist, G0151
health, physician, certification, G0179–G0182
health, respiratory therapy, S5180, S5181
recertification, home health, G0179
supervision, home health, G0181
supervision, hospice, G0182
therapist, speech, S9128
Home Health Agency Services, T0221, T1022
care improvement home visit assessment, G9187
Home sleep study test, G0398–G0400
HOPPS, C1000–C9999
Hospice care
assisted living facility, Q5002
hospice facility, Q5010
inpatient hospice facility, Q5006
inpatient hospital, Q5005
inpatient psychiatric facility, Q5008
long-term care facility, Q5007
nursing long-term facility, Q5003
patient’s home, Q5001
services, M1154, M1159, M1186 ◀
skilled nursing facility, Q5004
Hospice, evaluation, pre-election, G0337
Hospice physician supervision, G0182
Hospital
bed, E0250–E0304, E0328, E0329
observation, G0378, G0379
outpatient clinic visit, assessment, G0463
Hospital Outpatient Payment System, C1000–C9999
Hot water bottle, A9273
Human fibrinogen concentrate, J7178
Humidifier, A7046, E0550–E0563
durable, diring IPPB treatment, E0560
durable, extensive, IPPB, E0550
durable glass bottle type, for regulator, E0555
heated, used with positive airway pressure device, E0562
non-heated, used with positive airway pressure, E0561
 water chamber, humidifier, replacement, positive airway device, A7046
Hyalgan, J7321
Hyalomatrix, Q4117
Hyaluronan, J7326, J7327
derivative, J7332
durolane, J7318
gel-Syn, J7328
genvisc, J7320
hymovis, J7322
trivisc, J7329
Hyaluronate, sodium, J7317
Hyaluronidase, J3470, J9316
ovine, J3471–J3473
Hydralazine HCl, J0360
Hydraulic patient lift, E0630
Hydrocollator, E0225, E0239
Hydrocolloid dressing, A6234–A6241
Hydrocortisone
acetate, J1700
sodium phosphate, J1710
sodium succinate, J1720
Hydrogel dressing, A6231–A6233, A6242–A6248
Hydromorphone, J1170
Hydroxyprogesterone caproate, J1725–J1726, J1729
Hydroxyzine HCl, J3410
Hygienic item or device, disposable or non-disposable, any type, each, A9286
Hylan G-F 20, J7322
Hyoscyamine Sulfate, J1980
Hyperbaric oxygen chamber, topical, A4575
Hypertonic saline solution, J7130, J7131

I
Ibandronate sodium, J1740
Ibuprofen, J1741
Ibutilide Fumarate, J1742
Icatibant, J1744
Ice
cap, E0230
collar, E0230
Idarubicin HCl, J9211
Idursulfase, J1743
Ifosfamide, J9208
Iliac, artery, angiography, G0278
Iloprost, Q4074
Imaging, PET, G0219, G0235
any site, NOS, G0235
whole body, melanoma, non-covered indications, G0219
Imiglucerase, J1786
Immune globulin, J1575
Bivigam, 500 mg, J1556
Cuvitru, J1555
Flebogamma, J1572
Gammagard liquid, J1569
Gammaplex, J1557
Gamunex, J1561
HepaGam B, J1571
Hizentra, J1559
Intravenous services, supplies and accessories, Q2052
NOS, J1566
Octagam, J1568
Privigen, J1459
Rho(D), J2788, J2790, J2791
Rhophylac, J2791
Subcutaneous, J1562
Xembify, J1558
Immunization counseling, G0310–G0315 ◀
Immunosuppressive drug, not otherwise classified, J7599
Implant
access system, A4301
aqueous shunt, L8612
bimatoprost, intracameral implant, J7351
breast, L8600
buprenorphine implant, J0570
cochlear, L8614, L8619
collagen, urinary tract, L8603
dental, D3460, D5925, D6010–D6067, D6075–D6199
crown, provisional, D6085
endodontic endosseous implant, D3460
facial augmentation implant prosthesis, D5925
implant supported prosthetics, D6055–D6067, D6075–D6077
other implant services, D6080–D6199
 surgical placement, D6010–D6051
dextranomer/hyaluronic acid copolymer, L8604
ganciclovir, J7310
hallux, L8642
infusion pump, programmable, E0783, E0786
implantable, programmable, E0783
implantable, programmable, replacement, E0786
joint, L8630, L8641, L8658
interphalangeal joint spacer, silicone or equal, L8658
metacarpophalangeal joint implant, L8630
metatarsal joint implant, L8641
lacrimal duct, A4262, A4263
maintenance procedures, D6080
maxillofacial, D5913–D5937
auricular prosthesis, D5914
auricular prosthesis, replacement, D5927
cranial prosthesis, D5924
facial augmentation implant prosthesis, D5925
facial prosthesis, D5919
facial prosthesis, replacement, D5929
mandibular resection prosthesis, with guide flange, D5934
mandibular resection prosthesis, without guide flange, D5935
nasal prosthesis, D5913
nasal prosthesis, replacement, D5926
nasal septal prosthesis, D5922
obturator prosthesis, definitive, D5932
obturator prosthesis, modification, D5933
obturator prosthesis, surgical, D5931
obturator/prosthesis, interim, D5936
ocular prosthesis, D5916
ocular prosthesis, interim, D5923
orbital prosthesis, D5915
orbital prosthesis, replacement, D5928
trismus appliance, not for TM treatment, D5937
metacarpophalangeal joint, L8630
metatarsal joint, L8641
neurostimulator pulse generator, L8679, L8681–L8688
not otherwise specified, L8699
ocular, L8610
ossicular, L8613
osteogenesis stimulator, E0749
 percutaneous access system, A4301
removal, dental, D6100
repair, dental, D6090
replacement implantable intraspinal catheter, E0785
sinuva, J7402
synthetic, urinary, L8606
urinary tract, L8603, L8606
vascular graft, L8670
Implantable radiation dosimeter, A4650
Impregnated gauze dressing, A6222–A6230, A6231–A6233
Inclisiran, J1306 ◀
Incobotulinumtoxin a, J0588
Incontinence
appliances and supplies, A4310, A4331, A4332, A4360, A5071–A5075, A5081–A5093,
A5102–A5114
garment, A4520, T4521–T4543
adult sized disposable incontinence product, T4522–T4528
any type, e.g. brief, diaper, A4520
pediatric sized disposable incontinence product, T4529–T4532
youth sized disposable incontinence product, T4533–T4534
supply, A4335, A4356–A4360
bedside drainage bag, A4357
disposable external urethral clamp/compression device, A4360
external urethral clamp or compression device, A4356
incontinence supply, miscellaneous, A4335
urinary drainage bag, leg or abdomen, A4358
treatment system, E0740
Indium IN-111
carpromab pendetide, A9507
ibritumomab tiuxetan, A9542
labeled autologous platelets, A9571
labeled autologous white blood cells, A9570
oxyquinoline, A9547
pentetate, A9548
pentetreotide, A9572
satumomab, A4642
Index visit, M1196, M1204 ◀
Inebilizumab-cdon, J1823
Infliximab injection, J1745
Influenza
afluria, Q2035
 agriflu, Q2034
flulaval, Q2036
fluvirin, Q2037
fluzone, Q2038
immunization, documentation, G8482–G8484
not otherwise specified, Q2039
vaccine, administration, G0008
virus vaccine, Q2034–Q2039
Infusion
covid, M0249, M0250
pump, ambulatory, with administrative equipment, E0781
pump, continuous glucose sensing supplies for maintenance, A4226
pump, heparin, dialysis, E1520
pump, implantable, E0782, E0783
pump, implantable, refill kit, A4220
pump, insulin, E0784
pump, mechanical, reusable, E0779, E0780
pump, uninterrupted infusion of Epiprostenol, K0455
replacement battery, A4602
saline, J7030–J7060
supplies, A4219, A4221, A4222, A4225, A4230–A4232, E0776–E0791
therapy, other than chemotherapeutic drugs, Q0081, Q2054
Inhalation solution; (see also drug name), J7608–J7699, Q4074
Injection device, needle-free, A4210
Injections; (see also drug name), J0120–J2504, J0223, J0224, J0591, J0691, J0693, J0699,
J0741, J0742, J0791, J0896, J1201, J1303, J1305, J1426, J1427, J1429, J1445, J1448,
J1554, J1823, J1942–J1944, J2406, J2506, J2794, J2798, J3031, J3399, J7169, J7204,
J7208, J7311, J7313, J7314, J7320, J7321, J7332, J9032, J9036, J9037, J9039, J9044,✖
J9057, J9118, J9153, J9173, J9177, J9199, J9201, J9210, J9223, J9229, J9247, J9269,
J9271, J9272, J9299, J9308, J9309, J9313, J9314, J9316, J9317, J9348, J9349, J9353,
J9355, J9356, Q0244, Q0249, Q5112–Q5118, Q5122, Q5123, Q9950, Q9991, Q9992
ado-trastuzumab emtansine, 1 mg, J9354
aripiprazole, extended release, J0401
arthrography, sacroiliac, joint, G0259, G0260
carfilzomib, 1 mg, J9047
certolizumab pegol, J0717
dental service, D9610, D9630
other drugs/medicaments, by report, D9630
therapeutic parenteral drug, single administration, D9610
therapeutic parenteral drugs, two or more administrations, different medications,
D9612
 dermal filler (LDS), G0429
filgrastim, J1442
interferon beta-1a, IM, Q3027
interferon beta-1a, SC, Q3028
omacetaxtine mepesuccinate, 0.01 mg, J9262
pertuzumb, 1 mg, J9306
sculptra, 0.5 mg, Q2028
supplies for self-administered, A4211
vincristine, 1 mg, J9371
ziv-aflibercept, 1 mg, J9400
Inlay/onlay dental restoration, D2510–D2664
INR, monitoring, G0248–G0250
demonstration prior to initiation, home INR, G0248
physician review and interpretation, home INR, G0250
provision of test materials, home INR, G0249
Insertion tray, A4310–A4316
Instillation, hexaminolevulinate hydrochloride, A9589
Insulin, J1815, J1817, S5550–S5571
ambulatory, external, system, A9274
treatment, outpatient, G9147
Integra flowable wound matrix, Q4114
Interferon
Alpha, J9212–J9215
Beta-1a, J1826, Q3027, Q3028
Beta-1b, J1830
Gamma, J9216
Intermittent
assist device with continuous positive airway pressure device, E0470–E0472
limb compression device, E0676
peritoneal dialysis system, E1592
positive pressure breathing machine (IPPB), E0500
Interphalangeal joint, prosthetic implant, L8658, L8659
Interscapular thoracic prosthesis
endoskeletal, L6570
upper limb, L6350–L6370
Intervention, alcohol/substance (not tobacco), G0396–G0397
Intervention, tobacco, G9016
Intraconazole, J1835
Intraocular
lenses, V2630–V2632
Intraoral radiographs, dental, D0210–D0240
 intraoral-complete series, D0210
intraoral-occlusal image, D0420
intraoral-periapical-each additional image, D0230
intraoral-periapical-first radiographic image, D0220
Intrapulmonary percussive ventilation system, E0481
Intrauterine copper contraceptive, J7300
Inversion/eversion correction device, A9285
Iodine I-123
iobenguane, A9582
ioflupane, A9584
sodium iodide, A9509, A9516
Iodine I-125
serum albumin, A9532
sodium iodide, A9527
sodium iothalamate, A9554
Iodine I-131
iodinated serum albumin, A9524
sodium iodide capsule, A9517, A9528
sodium iodide solution, A9529–A9531
Iodine Iobenguane sulfate I-131, A9508
Iodine swabs/wipes, A4247
IPD
system, E1592
Ipilimumab, J9228
IPPB machine, E0500
Ipratropium bromide, inhalation solution, unit dose, J7644, J7645
Irinotecan, J9205, J9206
Iron
Dextran, J1750
sucrose, J1756
Irrigation solution for bladder calculi, Q2004
Irrigation supplies, A4320–A4322, A4355, A4397–A4400
irrigation supply, sleeve, each, A4397
irrigation syringe, bulb, or piston, each, A4320
irrigation tubing set, bladder irrigation, A4355
ostomy irrigation set, A4400
ostomy irrigation supply, bag, A4398
ostomy irrigation supply, cone/catheter, A4399
Irrigation/evacuation system, bowel
control unit, E0350
disposable supplies for, E0352
 manual pump enema, A4459
tubing, K1013
Isatuximab-irfc, J9227
Isavuconazonium, J1833
Islet, transplant, G0341–G0343, S2102
Isoetharine HCl, inhalation solution
concentrated, J7647, J7648
unit dose, J7649, J7650
Isolates, B4150, B4152
Isoproterenol HCl, inhalation solution
concentrated, J7657, J7658
unit dose, J7659, J7660
Isosulfan blue, Q9968
Item, non-covered, A9270
IUD, J7300, S4989
IV pole, each, E0776, K0105
Ixabepilone, J9207

J
Jacket
scoliosis, L1300, L1310
Jaw, motion, rehabilitation system, E1700–E1702
Jemperli, J9272
Jenamicin, J1580
Jetria, (ocriplasmin), J7316

K
Kadcyla, ado-trastuzumab emtansine, 1 mg, J9354
Kanamycin sulfate, J1840, J1850
Kartop patient lift, toilet or bathroom; (see also Lift), E0625
Keramatrix or kerasorb, J4165
Ketorolac thomethamine, J1885
Kidney
diagnosis of CKD stage 5, M1188 ◀
ESRD supply, A4650–A4927
machine, E1500–E1699
machine, accessories, E1500–E1699
system, E1510
 wearable artificial, E1632
Kits
enteral feeding supply (syringe) (pump) (gravity), B4034–B4036
fistula cannulation (set), A4730
parenteral nutrition, B4220–B4224
administration kit, per day, B4224
supply kit, home mix, per day, B4222
supply kit, premix, per day, B4220
surgical dressing (tray), A4550
tracheostomy, A4625
Knee
arthroscopy, surgical, G0289, S2112, S2300
knee, surgical, harvesting cartilage, S2112
knee, surgical, removal loose body, chondroplasty, different compartment, G0289
shoulder, surgical, thermally-induced, capsulorraphy, S2300
disarticulation, prosthesis, L5150, L5160
joint, miniature, L5826
orthosis (KO), E1810, L1800–L1885, K1014
dynamic adjustable elbow entension/flexion device, E1800
dynamic adjustable knee extension/flexion device, E1810
static-progressive devices, E1801, E1806, E1811, E1816–E1818, E1831, E1841
Knee-ankle-foot device with microprocessor control, L2006
Knee-ankle-foot orthosis (KAFO), K1007, L2000–L2039, L2126–L2136
addition, high strength, lightweight material, L2755
base procedure, used with any knee joint, double upright, double bar, L2020
base procedure, used with any knee joint, full plastic double upright, L2036
base procedure, used with any knee joint, single upright, single bar, L2000
foot orthrosis, double upright, double bar, without knee joint, L2030
foot orthrosis, single upright, single bar, without knee joint, L2010
Kovaltry, J7211
Kyphosis pad, L1020, L1025

L
Laboratory
dental, D0415–D0999
adjunctive pre-diagnostic tests, mucosal abnormalities, D0431
analysis saliva sample, D0418
caries risk assessment, low, D0601
caries risk assessment, moderate, D0602
caries susceptibility tests, D0425
 collection and preparation, saliva sample, D0417
collection of microorganisms for culture and sensitivity, D0415
diagnostic casts, D0470
oral pathology laboratory, D0472–D0502
processing, D0414
pulp vitality tests, D0460
services, P0000–P9999
viral culture, D0416
Laboratory tests
chemistry, P2028–P2038
cephalin flocculation, blood, P2028
congo red, blood, P2029
hair analysis, excluding arsenic, P2031
mucoprotein, blood, P2038
thymol turbidity, blood, P2033
microbiology, P7001
miscellaneous, P9010–P9615, Q0111–Q0115
blood, split unit, P9011
blood, whole, transfusion, unit, P9010
catheterization, collection specimen, multiple patients, P9615
catheterization, collection specimen, single patient, P9612
cryoprecipitate, each unit, P9012
fern test, Q0114
fresh frozen plasma, donor retested, each unit, P9060
fresh frozen plasma (single donor), frozen within 8 hours, P9017
fresh frozen plasma, within 8–24 hours of collection, each unit, P9059
granulocytes, pheresis, each unit, P9050
infusion, albumin (human), 25%, 20 ml, P9046
infusion, albumin (human), 25%, 50 ml, P9047
infusion, albumin (human), 5%, 250 ml, P9045
infusion, albumin (human), 5%, 50 ml, P9041
infusion, plasma protein fraction, human, 5%, 250 ml, P9048
infusion, plasma protein fraction, human, 5%, 50 ml, P9043
KOH preparation, Q0112
pinworm examinations, Q0113
plasma, cryoprecipitate reduced, each unit, P9044
plasma, pooled, multiple donor, frozen, P9023
platelet rich plasma, each unit, P9020
platelets, each unit, P9019
platelets, HLA-matched leukocytes reduced, apheresis/pheresis, each unit, P9052
platelets, irradiated, each unit, P9032
 platelets, leukocytes reduced, CMV-neg, aphresis/pheresis, each unit, P9055
platelets, leukocytes reduced, each unit, P9031
platelets, leukocytes reduced, irradiated, each unit, P9033
platelets, pheresis, each unit, P9034
platelets, pheresis, irradiated, each unit, P9036
platelets, pheresis, leukocytes reduced, CMV-neg, irradiated, each unit, P9053
platelets, pheresis, leukocytes reduced, each unit, P9035
platelets, pheresis, leukocytes reduced, irradiated, each unit, P9037
post-coital, direct qualitative, vaginal or cervical mucous, Q0115
red blood cells, deglycerolized, each unit, P9039
red blood cells, each unit, P9021
red blood cells, frozen/deglycerolized/washed, leukocytes reduced, irradiated, each unit,
P9057
red blood cells, irradiated, each unit, P9038
red blood cells, leukocytes reduced, CMV-neg, irradiated, each unit, P9058
red blood cells, leukocytes reduced, each unit, P9016
red blood cells, leukocytes reduced, irradiated, each unit, P9040
red blood cells, washed, each unit, P9022
travel allowance, one way, specimen collection, home/nursing home, P9603, P9604
wet mounts, vaginal, cervical, or skin, Q0111
whole blood, leukocytes reduced, irradiated, each unit, P9056
whole blood or red blood cells, leukocytes reduced, CMV-neg, each unit, P9051
whole blood or red blood cells, leukocytes reduced, frozen, deglycerol, washed, each
unit, P9054
toxicology, P3000–P3001, Q0091
Lacrimal duct, implant
permanent, A4263
temporary, A4262
Lactated Ringer’s infusion, J7120
Laetrile, J3570
Lanadelumab-flyo, J0593
Lancet, A4258, A4259
Language, screening, V5363
Lanreotide, J1930, J1932 ◀
Laronidase, J1931
Larynx, artificial, L8500
Laser blood collection device and accessory, A4257, E0620
LASIK, S0800
Lead investigation, T1029
Lead wires, per pair, A4557
Leg
 bag, A4358, A5105, A5112
leg or abdomen, vinyl, with/without tubes, straps, each, A4358
urinary drainage bag, leg bag, leg/abdomen, latex, with/without tube, straps, A5112
urinary suspensory, leg bag, with/without tube, each, A5105
extensions for walker, E0158
rest, elevating, K0195
rest, wheelchair, E0990
strap, replacement, A5113–A5114
Legg Perthes orthosis, L1700–L1755
Newington type, L1710
Patten bottom type, L1755
Scottish Rite type, L1730
Tachdjian type, L1720
Toronto type, L1700
Lens
aniseikonic, V2118, V2318
contact, V2500–V2599
gas permeable, V2510–V2513
hydrophilic, V2520–V2523
other type, V2599
PMMA, V2500–V2503
scleral, gas, V2530–V2531
eye, V2100–V2615, V2700–V2799
bifocal, glass or plastic, V2200–V2299
contact lenses, V2500–V2599
low vision aids, V2600–V2615
miscellaneous, V2700–V2799
single vision, glass or plastic, V2100–V2199
trifocal, glass or plastic, V2300–V2399
variable asphericity, V2410–V2499
intraocular, V2630–V2632
anterior chamber, V2630
iris supported, V2631
new technology, category 4, IOL, Q1004
new technology, category 5, IOL, Q1005
posterior chamber, V2632
telescopic lens, C1840
low vision, V2600–V2615
hand held vision aids, V2600
single lens spectacle mounted, V2610
telescopic and other compound lens system, V2615
 progressive, V2781
Lepirudin, J1945
Lesion, destruction, choroid, G0186
Leucovorin calcium, J0640
Leukocyte poor blood, each unit, P9016
Leuprolide acetate, J1950, J1951, J9217, J9219
for depot suspension, 7.5 mg, J9217
implant, 65 mg, J9219
injection, for depot suspension, per 3.75 mg, J1950
per 1 mg, J9218
Leuprolide injectable, camcevi, J1952 ◀
Levalbuterol, all formulations, inhalation solution
concentrated, J7607, J7612
unit dose, J7614, J7615
Levetiracetam, J1953
Levocarnitine, J1955
Levofloxacin, J1956
Levoleucovorin injection, J0641
Levoleucovorin injection (khapzory), J0642
Levonorgestrel, (contraceptive), implants and supplies, J7306
Levorphanol tartrate, J1960
Lexidronam, A9604
Lidocaine HCl, J2001
Lift
patient (includes seat lift), E0621–E0635
bathroom or toilet, E0625
mechanism incorporated into a combination liftchair, E0627
patient lift, electric, E0635
patient lift, hydraulic or mechanical, E0630
separate seat lift mechanism, patient owned furniture, non-electric, E0629
sling or seat, canvas or nylon, E0621
shoe, L3300–L3334
lift, elevation, heel, L3334
lift, elevation, heel and sole, cork, L3320
lift, elevation, heel and sole, Neoprene, L3310
lift, elevation, heel, tapered to metatarsals, L3300
lift, elevation, inside shoe, L3332
lift, elevation, metal extension, L3330
Lightweight, wheelchair, E1087–E1090, E1240–E1270
detachable arms, swing away detachable, elevating leg rests, E1240
detachable arms, swing away detachable footrest, E1260
 fixed full length arms, swing away detachable elevating legrests, E1270
fixed full length arms, swing away detachable footrest, E1250
high strength, detachable arms desk, E1088
high strength, detachable arms desk or full length, E1090
high strength, fixed full length arms, E1087
high strength, fixed length arms swing away footrest, E1089
Lincomycin HCl, J2010
Linezolid, J2020, J2021 ◀
Liquid barrier, ostomy, A4363
Listening devices, assistive, V5281–V5290
personal Bluetooth FM/DM, V5286
personal FM/DM adapter/boot coupling device for receiver, V5289
personal FM/DM binaural, 2 receivers, V5282
personal FM/DM, direct audio input, V5285
personal FM/DM, ear level receiver, V5284
personal FM/DM monaural, 1 receiver, V5281
personal FM/DM neck, loop induction receiver, V5283
personal FM/DM transmitter assistive listening device, V5288
transmitter microphone, V5290
Lodging, recipient, escort nonemergency transport, A0180, A0200
LOPS, G0245–G0247
follow-up evaluation and management, G0246
initial evaluation and management, G0245
routine foot care, G0247
Lorazepam, J2060
Loss of protective sensation, G0245–G0247
Low osmolar contrast material, Q9965–Q9967
Loxapine, for inhalation, J2062
LSO, L0621–L0640
Lubricant, A4332, A4402
Lumbar flexion, L0540
Lumbar-sacral orthosis (LSO), L0621–L0640
Lutetium, A9607 ◀
LVRS, services, G0302–G0305
Lymphocyte immune globulin, J7504, J7511
 M
Machine
IPPB, E0500
kidney, E1500–E1699
Magnesium sulphate, J3475
Maintenance contract, ESRD, A4890
Mammography, screening, G9899, G9900
Mannitol, J2150, J7665
Marker, tissue, A4648
Mask
aerosol, K0180
oxygen, A4620
Mastectomy
bra, L8000
form, L8020
prosthesis, L8030, L8600
sleeve, L8010
Matristem, Q4118
micromatrix, 1 mg, Q4118
Mattress
air pressure, E0186
alternating pressure, E0277
dry pressure, E0184
gel pressure, E0196
hospital bed, E0271, E0272
non-powered, pressure reducing, E0373
overlay, E0371–E0372
powered, pressure reducing, E0277
water pressure, E0187
Measurement period
ace inhibior, M1200, M1203 ◀
anaphylaxis, M1155 ◀
bone marrow transplant, M1157 ◀
chemotherapy, M1156 ◀
dementia, M1164 ◀
herpes zoster, M1174, M1176 ◀
hospice services, M1159, M1165, M1167, M1191 ◀
immunocompromising condition (history of), M1158 ◀
 influenza vaccine, M1168, M1170 ◀
left ventricular function testing, G8682
pneumococcal conjugate, M1179 ◀
td or tdap vaccine, M1171, M1173 ◀
Mecasermin, J2170
Mechlorethamine HCl, J9230
Medicaid, codes, T1000–T9999
Medical and surgical supplies, A4206–A8999
Medical nutritional therapy, G0270, G0271
Medical services, other, M0000–M9999
Medications, high-risk, M1209–M1210 ◀
Medroxyprogesterone acetate, J1050
Meloxicam, J1738
Melphalan flufenamide J9247
Melphalan NOS, J9245, J9246
Melphalan oral, J8600
Membrane graft/wrap, Q4205
Mental, health, training services, C7900–C7902, G0177 ◀
Meperidine, J2175
and promethazine, J2180
Mepivacaine HCl, J0670
Mepolizumab, J2182
Meropenem, J2184, J2185 ◀
Mesna, J9209
Metacarpophalangeal joint, prosthetic implant, L8630, L8631
Metaproterenol sulfate, inhalation solution
concentrated, J7667, J7668
unit dose, J7669, J7670
Metaraminol bitartrate, J0380
Metatarsal joint, prosthetic implant, L8641
Meter, bath conductivity, dialysis, E1550
Methacholine chloride, J7674
Methadone HCl, J1230
Methergine, J2210
Methocarbamol, J2800
Methotrexate
oral, J8610
sodium, J9250, J9260
Methyldopate HCl, J0210
Methylene blue, Q9968
Methylnaltrexone, J2212
Methylprednisolone
acetate, J1020–J1040
injection, 20 mg, J1020
injection, 40 mg, J1030
injection, 80 mg, J1040
oral, J7509
sodium succinate, J2920, J2930
Metoclopramide HCl, J2765
Micafungin sodium, J2247, J2248 ◀
Microbiology test, P7001
Midazolam HCl, J2250, J2251 ◀
Mileage
ALS, A0390
ambulance, A0380, A0390
Milrinone lactate, J2260
Mini-bus, nonemergency transportation, A0120
Minocycline hydrochloride, J2265
Miscellaneous and investigational, A9000–A9999
Mitomycin, J7315, J9280, J9281
Mitoxantrone HCl, J9293
MNT, G0270, G0271
Mobility device, physician, service, G0372
Modalities, with office visit, M0005–M0008
Mogamulizumab injection-kpkc, J9201
Moisture exchanger for use with invasive mechanical ventilation, A4483
Moisturizer, skin, A6250
Molecular pathology procedure, G0452
Monitor
blood glucose, home, E0607
blood pressure, A4670
pacemaker, E0610, E0615
Monitoring feature/device, A9279
Monitoring, INR, G0248–G0250
demonstration prior to initiation, G0248
physician review and interpretation, G0250
provision of test materials, G0249
Monoclonal antibodies, J7505
Morphine sulfate, J2270, J2272 ◀
epidural or intrathecal use, J2274
Motion, jaw, rehabilitation system, E1700–E1702
motion rehabilitation system, E1700
 replacement cushions, E1701
replacement measuring scales, E1702
Mouthpiece (for respiratory equipment), A4617
Moxetumomab pasudotox-tdfx, J9313
Moxifloxacin, J2280, J2281 ◀
Mucoprotein, blood, P2038
Multiaxial ankle, L5986
Multidisciplinary services, H2000–H2001, T1023–T1028
Multiple post collar, cervical, L0180–L0200
occipital/mandibular supports, adjustable, L0180
occipital/mandibular supports, adjustable cervical bars, L0200
SQMI, Guilford, Taylor types, L0190
Multi-Podus type AFO, L4396
Muromonab-CD3, J7505
Mycophenolate mofetil, J7517
Mycophenolic acid, J7518
MyOwn skin, Q4226

N
Nabilone, J8650
Nails, trimming, dystrophic, G0127
Nalbuphine HCl, J2300
Naloxone HCl, J2310, J2311 ◀
Naltrexone, J2315
Nandrolone
decanoate, J2320
Narrowing device, wheelchair, E0969
Nasal
application device, K0183
pillows/seals (for nasal application device), K0184
vaccine inhalation, J3530
Nasogastric tubing, B4081, B4082
Natalizumab, J2323
Nebulizer, E0570–E0585
aerosol compressor, E0571, E0572
aerosol mask, A7015
corrugated tubing, disposable, A7010
filter, disposable, A7013
filter, non-disposable, A7014
 heater, E1372
large volume, disposable, prefilled, A7008
large volume, disposable, unfilled, A7007
not used with oxygen, durable, glass, A7017
pneumatic, administration set, A7003, A7005, A7006
pneumatic, nonfiltered, A7004
portable, E0570
small volume, A7003–A7005
ultrasonic, E0575
ultrasonic, dome and mouthpiece, A7016
ultrasonic, reservoir bottle, non-disposable, A7009
water collection device, large volume nebulizer, A7012
Necitumumab, J9295
Needle, A4215
bone marrow biopsy, C1830
non-coring, A4212
with syringe, A4206–A4209
Negative pressure wound therapy pump, E2402
accessories, A6550
Nelarabine, J9261
Neonatal transport, ambulance, base rate, A0225
Neostigmine methylsulfate, J2710
Nerve, conduction, sensory, test, G0255
Nerve stimulator with batteries, E0765
Nesiritide injection, J2324, J2325
Neupogen, injection, filgrastim, 1 mcg, J1442
Neuromuscular stimulator, E0745
Neurophysiology, intraoperative, monitoring, G0453
Neurostimulator
battery recharging system, L8695
external antenna, L8696
implantable pulse generator, L8679
pulse generator, L8681–L8688
dual array, non-rechargeable, with extension, L8688
dual array, rechargeable, with extension, L8687
patient programmer (external), replacement only, L8681
radiofrequency receiver, L8682
radiofrequency transmitter (external), sacral root receiver, bowel and bladder
management, L8684
radiofrequency transmitter (external), with implantable receiver, L8683
single array, rechargeable, with extension, L8686
Nipple prosthesis, custom fabricated, reusable, L8033
Nipple prosthesis, prefabricated, reusable, L8032
Nitrogen N-13 ammonia, A9526
Nivol relatlimab, J9298 ◀
NMES, E0720–E0749
Nonchemotherapy drug, oral, NOS, J8499
Noncovered services, A9270
Nonemergency transportation, A0080–A0210
Nonimpregnated gauze dressing, A6216–A6221, A6402–A6404
Nonprescription drug, A9150
Not otherwise classified drug, J3490, J7599, J7699, J7799, J8499, J8999, J9999, Q0181
Novafix, Q4208
NPH, J1820
NPWT, pump, E2402
NTIOL category 3, Q1003
NTIOL category 4, Q1004
NTIOL category 5, Q1005
Nursing care, T1030–T1031
Nursing service, direct, skilled, outpatient, G0128
Nusinersen, J2326
Nutrition
counseling, dental, D1310, D1320
enteral infusion pump, B9002
parenteral infusion pump, B9004, B9006
parenteral solution, B4164–B5200
therapy, medical, G0270, G0271

O
O & P supply/accessory/service, L9900
Observation
admission, G0379
hospital, G0378
Obturator prosthesis
definitive, D5932
interim, D5936
surgical, D5931
Occipital/mandibular support, cervical, L0160
Occlusive device, placement, G0269
Occupational, therapy, G0129, S9129
Ocrelizumab, J2350
Ocriplasmin, J7316
Octafluoropropane, Q9956
Octagam, J1568
Octreotide acetate, J2353, J2354
Ocular prosthetic implant, L8610
Ofatumumab, J9302
Olanzapine, J2358
Olaratumab, J9285
Oliceridine, C9101 ◀
Omacetaxine Mepesuccinate, J9262
Omadacycline, J0121
Omalizumab, J2357
Omegaven, B4187
OnabotulinumtoxinA, J0585
Oncology
disease status, G9063–G9139
practice guidelines, G9056–G9062
visit, G9050–G9055
Ondansetron HCl, J2405
Ondansetron oral, Q0162
One arm, drive attachment, K0101
Ophthalmological examination, refraction, S0621
Oprelvekin, J2355
Oral and maxillofacial surgery, D7111–D7999
alveoloplasty, D7310–D7321
complicated suturing, D7911–D7912
excision of bone tissue, D7471–D7490
extractions, local, D7111–D7140
other repair procedures, D7920–D7999
other surgical procedures, D7260–D7295
reduction of dislocation/TMJ dysfunction, D7810–D7899
repair of traumatic wounds, D7910
surgical excision, intra-osseous lesions, D7440–D7465
surgical excision, soft tissue lesions, D7410–D7415
surgical extractions, D7210–D7251
surgical incision, D7510–D7560
treatment of fractures, compound, D7710–D7780
treatment of fractures, simple, D7610–D7680
vestibuloplasty, D7340–D7350
Oral device/appliance, E0485–E0486, K1028, K1029 ◀
Oral interface, A7047
Oral, NOS, drug, J8499
Oral/nasal mask, A7027
nasal pillows, A7029
oral cushion, A7028
Oritavancin, J2406, J2407
Oropharyngeal suction catheter, A4628
Orphenadrine, J2360
Orthodontics, D8000–D8999
Orthopedic shoes
arch support, L3040–L3100
footwear, L3000–L3649, L3201–L3265
insert, L3000–L3030
lift, L3300–L3334
miscellaneous additions, L3500–L3595
positioning device, K1015, L3140–L3170
transfer, L3600–L3649
wedge, L3340–L3420
Orthotic additions
carbon graphite lamination, L2755
fracture, L2180–L2192, L3995
halo, L0860
lower extremity, L2200–L2999, L4320
ratchet lock, L2430
scoliosis, L1010–L1120, L1210–L1290
shoe, L3300–L3595, L3649
spinal, L0970–L0984
upper limb, L3810–L3890, L3900, L3901, L3970–L3974, L3975–L3978, L3995
Orthotic devices
ankle-foot (AFO); (see also Orthopedic shoes), E1815, E1816, E1830, L1900–L1990,
L2102–L2116, L3160, L4361, L4397
anterior-posterior-lateral, L0700, L0710
cervical, L0100–L0200
cervical-thoracic-lumbar-sacral (CTLSO), L0700, L0710
elbow (EO), E1800, E1801, L3700–L3740, L3760–L3761, L3762
fracture, L2102–L2136, L3980–L3986
halo, L0810–L0830
hand, (WHFO), E1805, E1825, L3807, L3900–L3954, L3956
hand, finger, prefabricated, L3923
hip (HO), L1600–L1690
hip-knee-ankle-foot (HKAFO), L2040–L2090
 interface material, E1820
knee (KO), E1810, E1811, L1800–L1885
knee-ankle-foot (KAFO); (see also Orthopedic shoes), L2000–L2038, L2126–L2136
Legg Perthes, L1700–L1755
lumbar, L0625–L0651
multiple post collar, L0180–L0200
not otherwise specified, L0999, L1499, L2999, L3999, L5999, L7499, L8039, L8239
pneumatic splint, L4350–L4380
pronation/supination, E1818
repair or replacement, L4000–L4210
replace soft interface material, L4390–L4394
sacroiliac, L0600–L0620, L0621–L0624
scoliosis, L1000–L1499
shoe, (see Orthopedic shoes)
shoulder (SO), L1840, L3650, L3674, L3678
shoulder-elbow-wrist-hand (SEWHO), L3960–L3978
side bar disconnect, L2768
spinal, cervical, L0100–L0200
spinal, DME, K0112–K0116
thoracic, L0210, L0220
thoracic-hip-knee-ankle (THKO), L1500–L1520
toe, E1830
wrist-hand-finger (WHFO), E1805, E1806, E1825, L3806–L3809, L3900–L3954, L3956
Orthovisc, J7324
Ossicula prosthetic implant, L8613
Osteogenesis stimulator, E0747–E0749, E0760
Osteotomy, segmented or subapical, D7944
Ostomy
accessories, A5093
belt, A4396
pouches, A4416–A4435, A5056, A5057
skin barrier, A4401–A4449, A4462
supplies, A4361–A4421, A5051–A5149, A5200
Otto Bock, prosthesis, L7007
Outpatient payment system, hospital, C1000–C9999
Overdoor, traction, E0860
Oxacillin sodium, J2700
Oxaliplatin, J9263
Oxygen
ambulance, A0422
battery charger, E1357
 battery pack/cartridge, E1356
catheter, transtracheal, A7018
chamber, hyperbaric, topical, A4575
concentrator, E1390–E1391
DC power adapter, E1358
delivery system (topical), E0446
equipment, E0424–E0486, E1353–E1406
Liquid oxygen system, E0433
mask, A4620
medication supplies, A4611–A4627
rack/stand, E1355
regulator, E1352, E1353
respiratory equipment/supplies, E0424–E0480, A4611–A4627, E0481
supplies and equipment, E0425–E0444, E0455
tent, E0455
tubing, A4616
water vapor enriching system, E1405, E1406
wheeled cart, E1354
Oxymorphone HCl, J2410
Oxytetracycline HCl, J2460
Oxytocin, J2590

P
Pacemaker monitor, E0610, E0615
Pacemaker permanent insertion, C7537–C7578 ◀
Pacemaker removal, C7540 ◀
Paclitaxel, J9267
Paclitaxel protein-bound particles, J9264
Pad
correction, CTLSO, L1020–L1060
gel pressure, E0185, E0196
heat, A9273, E0210, E0215, E0217, E0238, E0249
electric heat pad, moist, E0215
electric heat pad, standard, E0210
hot water bottle, ice cap or collar, heat and/or cold wrap, A9273
pad for water circulating heat unit, replacement only, E0249
water circulating heat pad with pump, E0217
orthotic device interface, E1820
sheepskin, E0188, E0189
 water circulating cold with pump, E0218
water circulating heat unit, E0249
water circulating heat with pump, E0217
Pail, for use with commode chair, E0167
Pain assessment, G8730–G8732
Pain management, chronic, G3002–G3003 ◀
Palate, prosthetic implant, L8618
Palifermin, J2425
Paliperidone palmitate, J2426
Palonosetron, J2469, J8655
Pamidronate disodium, J2430
Pan, for use with commode chair, E0167
Panitumumab, J9303
Papanicolaou screening smear (Pap), P3000, P3001, Q0091
cervical or vaginal, up to 3 smears, by technician, P3000
cervical or vaginal, up to 3 smears, physician interpretation, P3001
obtaining, preparing and conveyance, Q0091
Papaverine HCl, J2440
Paraffin, A4265
bath unit, E0235
Parenteral nutrition
administration kit, B4224
not otherwise specified, B4185
pump, B9004, B9006
solution, B4164, B4184, B4186
compounded amino acid and carbohydrates, with electrolytes, B4189–B4199,
B5000–B5200
nutrition additives, homemix, B4216
nutrition administration kit, B4224
nutrition solution, amino acid, B4168–B4178
nutrition solution, carbohydrates, B4164, B4180
nutrition solution, per 10 grams, liquid, B4185
nutrition supply kit, homemix, B4222
supply kit, B4220, B4222
Paricalcitol, J2501
Parking fee, nonemergency transport, A0170
Partial Hospitalization, OT, G0129
Pasireotide long acting, J2502
Paste, conductive, A4558
Pathology and laboratory tests, miscellaneous, P9010–P9615
Pathology, surgical, G0416, M1193, M1195 ◀
Patient support system, E0636, M1207–M1208 ◀
Patient transfer system, E1035–E1036
Patisiran injection, J0222
Pediculosis (lice) treatment, A9180
PEFR, peak expiratory flow rate meter, A4614
Pegademase bovine, J2504
Pegaptanib, J2503
Pegaspargase, J9266
Pegfilgrastim, J2505, Q5122
Peginesatide, J0890
Pegloticase, J2507
Pelvic
belt/harness/boot, E0944
traction, E0890, E0900, E0947
Pemetrexed, J9304–J9305
Penicillin
G benzathine/G benzathine and penicillin G procaine, J0558, J0561
G potassium, J2540
G procaine, aqueous, J2510
Pentamidine isethionate, J2545, J7676
Pentastarch, 10% solution, J2513
Pentazocine HCl, J3070
Pentobarbital sodium, J2515
Pentostatin, J9268
Peramivir, J2547
Percussor, E0480
Percutaneous ◀
biliary drainage catheter, C7545 ◀
breast biopsies, C7501–C7502 ◀
vertebral augmentations, C7507–C7508 ◀
vertebroplasties, C7504–C7505 ◀
Percutaneous access system, A4301
Perflexane lipid microspheres, Q9955
Perflutren lipid microspheres, Q9957
Periapical service, D3410–D3470
apicoectomy, bicuspid, first root, D3421
apicoectomy, each additional root, D3426
apicoectomy, molar, first root, D3425
apicoectomy/periradicular surgery-anterior, D3410
biological materials, aid soft and osseous tissue regeneration/periradicular surgery,
D3431
 bone graft, per tooth, periradicular surgery, D3429
endodonic endosseous implant, D3460
guided tissue regeneration/periradicular surgery, D3432
intentional replantation, D3470
periradicular surgery without apicoectomy, D3427
retrograde filling, per root, D3430
root amputation, D3450
Periodontal procedures, D4000–D4999
Periodontics, dental, D4000–D4999
Peroneal strap, L0980
Peroxide, A4244
Perphenazine, J3310
Personal care services, T1019–T1021
home health aide or CAN, per visit, T1021
per diem, T1020
provided by home health aide or CAN, per 15 minutes, T1019
Pertuzumab, J9306, J9316
Pessary, A4561, A4562
PET, G0219, G0235, G0252
Pharmacologic therapy, G8633
Pharmacy, fee, G0333
Phenobarbital sodium, J2560
Phentolamine mesylate, J2760
Phenylephrine HCl, J2370
Phenylephrine/ketorolac ophthalmic solution, J1097
Phenytoin sodium, J1165
Phisohex solution, A4246
Photofrin, (see Porfimer sodium)
Photorefraction keratectomy, (PRK), S0810
Phototherapeutic keratectomy, (PTK), S0812
Phototherapy light, E0202
Phytonadione, J3430
Pillow, cervical, E0943
Pin retention (per tooth), D2951
Pinworm examination, Q0113
Plasma
multiple donor, pooled, frozen, P9023, P9070
single donor, fresh frozen, P9017, P9071
Plasminogen, J2998 ◀
Plastazote, L3002, L3252, L3253, L3265, L5654–L5658
addition to lower extremity socket insert, L5654
 addition to lower extremity socket insert, above knee, L5658
addition to lower extremity socket insert, below knee, L5655
addition to lower extremity socket insert, knee disarticulation, L5656
foot insert, removable, plastazote, L3002
foot, molded shoe, custom fitted, plastazote, L3253
foot, shoe molded to patient model, plastazote, L3252
plastazote sandal, L3265
Platelet, P9073, P9100
concentrate, each unit, P9019
rich plasma, each unit, P9020
Platelets, P9031–P9037, P9052–P9053, P9055
Platform attachment
forearm crutch, E0153
walker, E0154
Plazomicin injection, J0291
Plerixafor, J2562
Plicamycin, J9270
Plumbing, for home ESRD equipment, A4870
Pneumatic
appliance, E0655–E0673, L4350–L4380
compressor, E0650–E0652
splint, L4350–L4380
ventricular assist device, Q0477, Q0480–Q0505
Pneumatic nebulizer
administration set, small volume, filtered, A7006
administration set, small volume, nonfiltered, A7003
administration set, small volume, nonfiltered, nondisposable, A7005
small volume, disposable, A7004
Pneumococcal
vaccine, administration, G0009
Polatuzumab vedotin-piiq, J9309
Pontics, D6210–D6252
Porfimer sodium, J9600
Portable
equipment transfer, R0070–R0076
gaseous oxygen, K0741, K0742
hemodialyzer system, E1635
liquid oxygen system, E0433
x-ray equipment, Q0092
Positioning seat, T5001
Positive airway pressure device, accessories, A7030–A7039, E0561–E0562
Positive expiratory pressure device, E0484
Post-coital examination, Q0115
Postural drainage board, E0606
Potassium
chloride, J3480
hydroxide preparation(KOH), Q0112
Pouch
fecal collection, A4330
ostomy, A4375–A4378, A5051–A5054, A5061–A5065
urinary, A4379–A4383, A5071–A5075
Practice, guidelines, oncology, G9056–G9062
Pralatrexate, J9307
Pralidoxime chloride, J2730
Prednisolone
acetate, J2650
oral, J7510
Prednisone, J7512
Prefabricated crown, D2930–D2933
Preparation kits, dialysis, A4914
Preparatory prosthesis, L5510–L5595
chemotherapy, J8999
nonchemotherapy, J8499
Prescription digital behavioral therapy, A9291 ◀
Pressure
alarm, dialysis, E1540
pad, A4640, E0180–E0199
Pressure sensor system, C1834 ◀
Preventive dental procedures, D1000–D1999
Privigen, J1459
Procainamide HCl, J2690
Procedure
HALO, L0810–L0861
noncovered, G0293, G0294
scoliosis, L1000–L1499
Prochlorperazine, J0780
Progenamatrix, Q4222
Prolonged Service ◀
home or residence, G0318 ◀
hospital inpatient/observation, G0316 ◀
nursing facility, G0317 ◀
Prolotherapy, M0076
Promazine HCl, J2950
Promethazine
and meperdine, J2180
HCl, J2550
Propranolol HCl, J1800
Prostate, cancer, screening, G0102, G0103
Prosthesis
artificial larynx battery/accessory, L8505
auricular, D5914
breast, L8000–L8035, L8600
dental, D5911–D5960, D5999
eye, L8610, L8611, V2623–V2629
fitting, L5400–L5460, L6380–L6388
foot/ankle one piece system, L5979
hand, L6000–L6020, L6026
implants, L8600–L8690
larynx, L8500
lower extremity, L5700–L5999, L8640–L8642
mandible, L8617
maxilla, L8616
maxillofacial, provided by a non-physician, L8040–L8048
miscellaneous service, L8499
obturator, D5931–D5933, D5936
ocular, V2623–V2629
repair of, L7520, L8049
socks (shrinker, sheath, stump sock), L8400–L8485
taxes, orthotic/prosthetic/other, L9999
tracheo-esophageal, L8507–L8509
upper extremity, L6000–L6999
vacuum erection system, L7900
Prosthetic additions
lower extremity, L5610–L5999
powered upper extremity range of motion assist device, L8701–L8702
upper extremity, L6600–L7405
Prosthetic, eye, V2623
Prosthodontic procedure
fixed, D6200–D6999
removable, D5000–D5899
Prosthodontics, removable, D5110–D5899
Protamine sulfate, J2720
Protectant, skin, A6250
Protector, heel or elbow, E0191
Protein C Concentrate, J2724
Protirelin, J2725
Psychotherapy, group, partial hospitalization, G0410–G0411
Pulp capping, D3110, D3120
Pulpotomy, D3220
partial, D3222
vitality test, D0460
Pulse generator, E2120
Pump
alternating pressure pad, E0182
ambulatory infusion, E0781, E0787
ambulatory insulin, E0784
blood, dialysis, E1620
breast, E0602–E0604
enteral infusion, B9000, B9002
external infusion, E0779
heparin infusion, E1520
implantable infusion, E0782, E0783
implantable infusion, refill kit, A4220
infusion, supplies, A4226, A4230, A4232
negative pressure wound therapy, E2402
parenteral infusion, B9004, B9006
suction, portable, E0600
water circulating pad, E0236
wound, negative, pressure, E2402
Purification system, E1610, E1615
Pyridoxine HCl, J3415

Q
Quad cane, E0105
Quinupristin/dalfopristin, J2770

R
Rack/stand, oxygen, E1355
Radiesse, Q2026
Radioelements for brachytherapy, Q3001
Radiograph, dental, D0210–D0340
Radiological, supplies, A4641, A4642
Radiology service, R0070–R0076
Radiopharmaceutical diagnostic and therapeutic imaging agent, A4641, A4642,
A9500–A9699
Radiosurgery, robotic, G0339–G0340
Radiosurgery, stereotactic, G0339, G0340
Rail
bathtub, E0241, E0242, E0246
bed, E0305, E0310
toilet, E0243
Ranibizumab, J2778
Rasburicase, J2783
Ravulizumab injection-cwvz, J1303
Reaching/grabbing device, A9281
Reagent strip, A4252
Re-cement
crown, D2920
inlay, D2910
Reciprocating peritoneal dialysis system, E1630
Reclast, J3488, J3489
Reclining, wheelchair, E1014, E1050–E1070, E1100–E1110
Reconstruction, angiography, G0288
Rectal Control System for Vaginal insertion, A4563
Red blood cells, P9021, P9022
Regadenoson, J2785
Regular insulin, J1815, J1820
Regulator, oxygen, E1353
Rehabilitation
cardiac, S9472
program, H2001
psychosocial, H2017, H2018
pulmonary, S9473
system, jaw, motion, E1700–E1702
vestibular, S9476
Releuko, Q5125 ◀
Remdesivir, J0248 ◀
Removal, cerumen, G0268
Repair
contract, ESRD, A4890
durable medical equipment, E1340
maxillofacial prosthesis, L8049
 orthosis, L4000–L4130
prosthetic, L7500, L7510
Replacement
battery, A4630
pad (alternating pressure), A4640
tanks, dialysis, A4880
tip for cane, crutches, walker, A4637
underarm pad for crutches, A4635
Resin dental restoration, D2330–D2394
Reslizumab, J2786
Respiratory
DME, A7000–A7527
equipment, E0424–E0601
function, therapeutic, procedure, G0237–G0239, S5180–S5181
supplies, A4604–A4629
Restorative dental procedure, D2000–D2999
Restraint, any type, E0710
Reteplase, J2993
Revascularization, C9603–C9608
Revefenacin inhalation solution, J7677
Rho(D) immune globulin, human, J2788, J2790, J2792
Rib belt, thoracic, A4572, L0220
Rilanocept, J2793
RimabotulinumtoxinB, J0587
Ring, ostomy, A4404
Ringers lactate infusion, J7120
Risankizumab, J2327 ◀
Risk-adjusted functional status
elbow, wrist or hand, G8667–G8670
hip, G8651–G8654
lower leg, foot or ankle, G8655–G8658
lumbar spine, G8659–G8662
neck, cranium, mandible, thoracic spine, ribs, or other, G8671–G8674
shoulder, G8663–G8666
Risperidone (risperdal consta), J2794
(perseris), J2798
Rituximab, J9312
abbs (Truxina), Q5115
Robin-Aids, L6000, L6010, L6020, L6855, L6860
Rocking bed, E0462
Rolapitant, J8670
Rollabout chair, E1031
Romidepsin, J9315
Romiplostim, J2796
Romosozumab injection-aqqg, J3111
Root canal therapy, D3310–D3353
Ropivacaine HCl, J2795
Rubidium Rb-82, A9555
Rybrevant, J9061
Rylaze, J9021

S
Sacituzumab govitecan-hziy, J9317
Sacral nerve stimulation test lead, A4290
Safety equipment, E0700
vest, wheelchair, E0980
Saline
hypertonic, J7130, J7131
infusion, J7030–J7060
solution, A4216–A4218, J7030–J7050
Saliva
artificial, A9155
collection and preparation, D0417
Samarium SM 153 Lexidronamm, A9605
Sargramostim (GM-CSF), J2820
Scale, E1639
Scoliosis, L1000–L1499
additions, L1010–L1120, L1210–L1290
Screening
alcohol misuse, G0442
cancer, cervical or vaginal, G0101
colorectal, cancer, G0104–G0106, G0120–G0122, G0328
cytopathology cervical or vaginal, G0123, G0124, G0141–G0148
depression, G0444
dysphagia, documentation, V5364
enzyme immunoassay, G0432
glaucoma, G0117, G0118
infectious agent antibody detection, G0433, G0435
language, V5363
mammography, digital image, G9899, G9900
prostate, cancer, G0102, G0103
 speech, V5362
Sculptra, Q2028
Sealant
skin, A6250
tooth, D1351
Seat
attachment, walker, E0156
insert, wheelchair, E0992
lift (patient), E0621, E0627–E0629
upholstery, wheelchair, E0975, E0981
Sebelipase alfa, J2840
Secretin, J2850
Semen analysis, G0027
Semi-reclining, wheelchair, E1100, E1110
Sensitivity study, P7001
Sensory nerve conduction test, G0255
Sermorelin acetate, Q0515
Serum clotting time tube, A4771
Service
Allied Health, home health, hospice, G0151–G0161
behavioral health and/or substance abuse, H0001–H9999
doula birth worker, T1032–T1033 ◀
hearing, V5000–V5999
laboratory, P0000–P9999
mental, health, training, G0177
non-covered, A9270
physician, for mobility device, G0372
pulmonary, for LVRS, G0302–G0305
skilled, RN/LPN, home health, hospice, G0162
social, psychological, G0409–G0411
speech-language, V5336–V5364
vision, V2020–V2799
SEWHO, L3960–L3974, L3975–L3978
SEXA, G0130
Sheepskin pad, E0188, E0189
Shoes
arch support, L3040–L3100
for diabetics, A5500–A5514
insert, L3000–L3030, L3031
lift, L3300–L3334
miscellaneous additions, L3500–L3595
 orthopedic, L3201–L3265
positioning device, L3140–L3170
transfer, L3600–L3649
wedge, L3340–L3485
Shoulder
disarticulation, prosthetic, L6300–L6320, L6550
orthosis (SO), L3650–L3674
spinal, cervical, L0100–L0200
Shoulder sling, A4566
Shoulder-elbow-wrist-hand orthosis (SEWHO), L3960–L3969, L3971–L3978
Shunt accessory for dialysis, A4740
aqueous, L8612
Sigmoidoscopy, cancer screening, G0104, G0106
Siltuximab, J2860
Sincalide, J2805
Sipuleucel-T, Q2043
Sirolimus, J7520, J9331 ◀
Sitz bath, E0160–E0162
Skin
barrier, ostomy, A4362, A4363, A4369–A4373, A4385, A5120
bond or cement, ostomy, A4364
sealant, protectant, moisturizer, A6250
substitute, Q4100–Q4258
Sling, A4565
patient lift, E0621, E0630, E0635
Smear, Papanicolaou, screening, P3000, P3001, Q0091
SNCT, G0255
Social worker, clinical, home, health, G0155
Social worker, nonemergency transport, A0160
Social work/psychological services, CORF, G0409
Sock
body sock, L0984
prosthetic sock, L8417, L8420–L8435, L8470, L8480, L8485
stump sock, L8470–L8485
Sodium
chloride injection, J2912
ferric gluconate complex in sucrose, J2916
fluoride F-18, A9580
hyaluronate
Euflexxa, J7323
GELSYN-3, J7328
 Hyalgan, J7321
Orthovisc, J7324
Supartz, J7321
Synvisc and Synvisc-One, J7325
Visco-3, J7321
phosphate P32, A9563
pyrophosphate, J1443
succinate, J1720
Solution
calibrator, A4256
dialysate, A4760
elliotts b, J9175
enteral formulae, B4149–B4156, B4157–B4162
parenteral nutrition, B4164–B5200
Solvent, adhesive remover, A4455
Somatrem, J2940
Somatropin, J2941
Sorbent cartridge, ESRD, E1636
Special size, wheelchair, E1220–E1239
Specialty absorptive dressing, A6251–A6256
Spectacle lenses, V2100–V2199
Spectinomycin HCl, J3320
Speech assessment, V5362–V5364
Speech generating device, E2500–E2599, K1009
Speech, pathologist, G0153
Speech-Language pathology, services, V5336–V5364
Spherocylinder, single vision, V2100–V2114
bifocal, V2203–V2214
trifocal, V2303–V2314
Spinal orthosis
cervical, L0100–L0200
cervical-thoracic-lumbar-sacral (CTLSO), L0700, L0710
DME, K0112–K0116
halo, L0810–L0830
multiple post collar, L0180–L0200
scoliosis, L1000–L1499
torso supports, L0960
Splint, A4570, L3100, L4350–L4380
ankle, L4390–L4398
dynamic, E1800, E1805, E1810, E1815, E1825, E1830, E1840
footdrop, L4398
 supplies, miscellaneous, Q4051
Standard, wheelchair, E1130, K0001
Static progressive stretch, E1801, E1806, E1811, E1816, E1818, E1821
Status
disease, oncology, G9063–G9139
STELARA, ustekinumab, 1 mg, J3357
Stent, transcatheter, placement, C9600, C9601
Stereotactic, radiosurgery, G0339, G0340
Sterile cefuroxime sodium, J0697
Sterile water, A4216–A4217
Stimulation, electrical, non-attended, G0281–G0283
Stimulators
neuromuscular, E0744, E0745
osteogenesis, electrical, E0747–E0749
salivary reflex, E0755
stoma absorptive cover, A5083
transcutaneous, electric, nerve, A4595–A4596, E0720–E0749 ◀
ultrasound, E0760
Stockings
gradient, compression, A6530–A6549
surgical, A4490–A4510
Stoma, plug or seal, A5081
Stomach tube, B4083
Streptokinase, J2995
Streptomycin, J3000
Streptozocin, J9320
Strip, blood glucose test, A4253–A4772
urine reagent, A4250
Strontium-89 chloride, supply of, A9600
Study, bone density, G0130
Stump sock, L8470–L8485
Stylet, A4212
Substance/Alcohol, assessment, G0396, G0397, H0001, H0003, H0049
Succinylcholine chloride, J0330
Suction pump
gastric, home model, E2000
portable, E0600
respiratory, home model, E0600
Sumatriptan succinate, J3030
Supartz, J7321
Supplies
 battery, A4233–A4236, A4601, A4611–A4613, A4638
cast, A4580, A4590, Q4001–Q4051
catheters, A4300–A4306
continuous glucose monitor, A4238, A4239 ◀
contraceptive, A4267–A4269
diabetic shoes, A5500–A5513
dialysis, A4653–A4928
DME, other, A4630–A4640
dressings, A6000–A6513
enteral, therapy, B4000–B9999
incontinence, A4310–A4355, A5102–A5200
infusion, A4221, A4222, A4230–A4232, E0776–E0791
needle, A4212, A4215
needle-free device, A4210
ostomy, A4361–A4434, A5051–A5093, A5120–A5200
parenteral, therapy, B4000–B9999
radiological, A4641, A4642
refill kit, infusion pump, A4220
respiratory, A4604–A4629
self-administered injections, A4211
splint, Q4051
sterile water/saline and/or dextrose, A4216–A4218
surgical, miscellaneous, A4649
syringe, A4206–A4209, A4213, A4232
syringe with needle, A4206–A4209
urinary, external, A4356–A4360
Supply/accessory/service, A9900
Support
arch, L3040–L3090
cervical, L0100–L0200
spinal, L0960
stockings, L8100–L8239
Surederm, Q4220
Surgery, oral, D7000–D7999
Surgical
arthroscopy, knee, G0289, S2112
boot, L3208–L3211
dressing, A6196–A6406
procedure, noncovered, G0293, G0294
stocking, A4490–A4510
supplies, A4649
 tray, A4550
Surgicord, Q4218–Q4219
Surgraft, Q4209, Q4263 ◀
Susvimo, J2779 ◀
Sutimlimab-jome, J1302 ◀
Swabs, betadine or iodine, A4247
Synojoynt, J7331
Synvisc and Synvisc-One, J7325
Syringe, A4213
with needle, A4206–A4209
System
external, ambulatory insulin, A9274
rehabilitation, jaw, motion, E1700–E1702
transport, E1035–E1039

T
Tables, bed, E0274, E0315
Tacrolimus
oral, J7503, J7507, J7508
parenteral, J7525
Tagraxofusp injections-erzs, J9269
Taliglucerase, J3060
Talimogene laheroareovec, J9325
Tape, A4450–A4452
Taxi, non-emergency transportation, A0100
Team, conference, G0175, G9007, S0220, S0221
Tebentafusp-tebn, J9274 ◀
Technetium TC 99M
Arcitumomab, A9568
Bicisate, A9557
Depreotide, A9536
Disofenin, A9510
Exametazine, A9521
Exametazine labeled autologous white blood cells, A9569
Fanolesomab, A9566
Glucepatate, A9550
Labeled red blood cells, A9560
Macroaggregated albumin, A9540
Mebrofenin, A9537
 Mertiatide, A9562
Oxidronate, A9561
Pentetate, A9539, A9567
Pertechnetate, A9512
Pyrophosphate, A9538
Sestamibi, A9500
Succimer, A9551
Sulfur colloid, A9541
Teboroxime, A9501
Tetrofosmin, A9502
Tilmanocept, A9520
Tedizolid phosphate, J3090
TEEV, J0900
Telavancin, J3095
Telehealth, Q3014, G0320–G0321 ◀
Telehealth transmission, T1014
Temozolomide
injection, J9328
oral, J8700
Temporary codes, Q0000–Q9999, S0009–S9999
Temporomandibular joint, D0320, D0321
Temsirolimus, J9330
Tenecteplase, J3101
Teniposide, Q2017
TENS, A4595–A4596, E0720–E0749 ◀
Tent, oxygen, E0455
Teprotumumab-trbw, J3241
Terbutaline sulfate, J3105
inhalation solution, concentrated, J7680
inhalation solution, unit dose, J7681
Teriparatide, J3110
Terminal devices, L6700–L6895
Test
sensory, nerve, conduction, G0255
Testosterone
cypionate and estradiol cypionate, J1071
enanthate, J3121
undecanoate, J3145
Tetanus immune globulin, human, J1670
Tetracycline, J0120
Tezepelumab, J2356 ◀
Thallous Chloride TL 201, A9505
Theophylline, J2810
Therapeutic lightbox, A4634, E0203
Therapy
activity, G0176
electromagnetic, G0295, G0329
endodontic, D3222–D3330
enteral, supplies, B4000–B9999
immune checkpoint inhibitor, M1180 ◀
medical, nutritional, G0270, G0271
occupational, G0129, H5300, S9129
occupational, health, G0152
parenteral, supplies, B4000–B9999
respiratory, function, procedure, G0237–S0239, S5180, S5181
speech, home, G0153, S9128
wound, negative, pressure, pump, E2402
Theraskin, Q4121
Thermometer, A4931–A4932
dialysis, A4910
Thiamine HCl, J3411
Thiethylperazine maleate, J3280
Thiotepa, J9340
Thoracic orthosis, L0210
Thoracic-hip-knee-ankle (THKAO), L1500–L1520
Thoracic-lumbar-sacral orthosis (TLSO)
scoliosis, L1200–L1290
spinal, L0450–L0492
Thymol turbidity, blood, P2033
Thyroidectomy, C7555 ◀
Thyrotropin Alfa, J3240
Tigecycline, J3243, J3244 ◀
Tinzarparin sodium, J1655
Tip (cane, crutch, walker) replacement, A4637
Tire, wheelchair, E2211–E2225, E2381–E2395
Tirofiban, J3246
Tisagenlecleucel, Q2040
Tisotumab vedotin-TFTV, J9273 ◀
Tissue marker, A4648
Tixagev and cilgav, Q0221 ◀
TLSO, L0450–L0492, L1200–L1290
Tobacco
 intervention, G9016
Tobramycin
inhalation solution, unit dose, J7682, J7685
sulfate, J3260
Tocilizumab, J2362
Toe device, E1831
Toilet accessories, E0167–E0179, E0243, E0244, E0625
Tolazoline HCl, J2670
Toll, non emergency transport, A0170
Tomographic radiograph, dental, D0322
Topical hyperbaric oxygen chamber, A4575
Topotecan, J8705, J9351
Torsemide, J3265
Trabectedin, J9352
Tracheostoma heat moisture exchange system, A7501–A7509
Tracheostomy
care kit, A4629
filter, A4481
speaking valve, L8501
supplies, A4623, A4629, A7523–A7524
tube, A7520–A7522
Tracheotomy mask or collar, A7525–A7526
Traction
cervical, E0855, E0856
device, ambulatory, E0830
equipment, E0840–E0948
extremity, E0870–E0880
pelvic, E0890, E0900, E0947
Training
diabetes, outpatient, G0108, G0109
home health or hospice, G0162
services, mental, health, G0177
Transcutaneous electrical nerve stimulator (TENS), E0720–E0770, K1016–K1020
Transducer protector, dialysis, E1575
Transfer (shoe orthosis), L3600–L3640
Transfer system with seat, E1035
Transparent film (for dressing), A6257–A6259
Transplant
heart (history of), M1151–M1152 ◀
islet, G0341–G0343, S2102
Transport
 chair, E1035–E1039
system, E1035–E1039
x-ray, R0070–R0076
Transportation
ambulance, A0021–A0999, Q3019, Q3020
corneal tissue, V2785
EKG (portable), R0076
handicapped, A0130
non-emergency, A0080–A0210, T2001–T2005
service, including ambulance, A0021, A0999, T2006
taxi, non-emergency, A0100
toll, non-emergency, A0170
volunteer, non-emergency, A0080, A0090
x-ray (portable), R0070, R0075, R0076
Transportation services
air services, A0430, A0431, A0435, A0436
ALS disposable supplies, A0398
ALS mileage, A0390
ALS specialized service, A0392, A0394, A0396
ambulance, ALS, A0426, A0427, A0433
ambulance, outside state, Medicaid, A0021
ambulance oxygen, A0422
ambulance, waiting time, A0420
ancillary, lodging, escort, A0200
ancillary, lodging, recipient, A0180
ancillary, meals, escort, A0210
ancillary, meals, recipient, A0190
ancillary, parking fees, tolls, A0170
BLS disposable supplies, A0382
BLS mileage, A0380
BLS specialized service, A0384
emergency, neonatal, one-way, A0225
extra ambulance attendant, A0424
ground mileage, A0425
non-emergency, air travel, A0140
non-emergency, bus, A0110
non-emergency, case worker, A0160
non-emergency, mini-bus, A0120
non-emergency, no vested interest, A0080
non-emergency, taxi, A0100
non-emergency, wheelchair van, A0130
 non-emergency, with vested interest, A0090
paramedic intercept, A0432
response and treat, no transport, A0998
specialty transport, A0434
Transtracheal oxygen catheter, A7018
Trapeze bar, E0910–E0912, E0940
Trauma, response, team, G0390
Tray
insertion, A4310–A4316
irrigation, A4320
surgical; (see also kits), A4550
wheelchair, E0950
Trastuzumab injection excludes biosimilar, J9316, J9355
anns (kanjinti), Q5117
dkst (Ogivri), Q5114
dttb (Ontruzant), Q5112
fam-trastuzumab deruxtecan-nxki, J9358
pkrb (Herzuma), Q5113
qyyp (trazimera), Q5116
Trastuzumab and Hyaluronidase-oysk, J9356
Treatment
bone, G0412–G0415
pediculosis (lice), A9180
services, behavioral health, H0002–H2037
Treprostinil, J3285
Triamcinolone, J3301–J3303
acetonide, J3300, J3301
diacetate, J3302
hexacetonide, J3303
inhalation solution, concentrated, J7683
inhalation solution, unit dose, J7684
Triferic avnu J1445
Triflupromazine HCl, J3400
Trifocal, glass or plastic, V2300–V2399
aniseikonic, V2318
lenticular, V2315, V2321
specialty trifocal, by report, V2399
sphere, plus or minus, V2300–V2302
spherocylinder, V2303–V2314
trifocal add-over 3.25d, V2320
trifocal, seg width over 28 mm, V2319
Trigeminal division block anesthesia, D9212
Trilaciclib J1448
Triluron intraarticular injection, J7332
Trimethobenzamide HCl, J3250
Trimetrexate glucuoronate, J3305
Trimming, nails, dystrophic, G0127
Triptorelin pamoate, J3315
Trismus appliance, D5937
Truss, L8300–L8330
addition to standard pad, scrotal pad, L8330
addition to standard pad, water pad, L8320
double, standard pads, L8310
single, standard pad, L8300
Tube/Tubing
anchoring device, A5200
blood, A4750, A4755
corrugated tubing, non-disposable, used with large volume nebulizer, 10 feet, A4337
drainage extension, A4331
gastrostomy, B4087, B4088
irrigation, A4355
larynectomy, A4622
nasogastric, B4081, B4082
oxygen, A4616
serum clotting time, A4771
stomach, B4083
suction pump, each, A7002
tire, K0091, K0093, K0095, K0097
tracheostomy, A4622
urinary drainage, K0280

U
Ultrasonic nebulizer, E0575
Ultrasound, S8055, S9024
paranasal sinus ultrasound, S9024
ultrasound guidance, multifetal pregnancy reduction, technical component, S8055
Ultraviolet, cabinet/system, E0691, E0694
Ultraviolet light therapy system, A4633, E0691–E0694
light therapy system in 6 foot cabinet, E0694
replacement bulb/lamp, A4633
therapy system panel, 4 foot, E0692
 therapy system panel, 6 foot, E0693
treatment area 2 sq feet or less, E0691
Unclassified drug, J3490
Underpads, disposable, A4554
Unipuncture control system, dialysis, E1580
Upper extremity addition, locking elbow, L6693
Upper extremity fracture orthosis, L3980–L3999
Upper limb prosthesis, L6000–L7499
Urea, J3350
Ureterostomy supplies, A4454–A4590
Urethral suppository, Alprostadil, J0275
Urinal, E0325, E0326
Urinary
catheter, A4338–A4346, A4351–A4353
indwelling catheter, A4338–A4346
intermittent urinary catheter, A4351–A4353
male external catheter, A4349
collection and retention (supplies), A4310–A4360
bedside drainage bag, A4357
disposable external urethral clamp, A4360
external urethral clamp, A4356
female external urinary collection device, A4328
insertion trays, A4310–A4316, A4354–A4355
irrigation syringe, A4322
irrigation tray, A4320
male external catheter/integral collection chamber, A4326
perianal fecal collection pouch, A4330
therapeutic agent urinary catheter irrigation, A4321
urinary drainage bag, leg/abdomen, A4358
supplies, external, A4335, A4356–A4358
bedside drainage bag, A4357
external urethral clamp/compression device, A4356
incontinence supply, A4335
urinary drainage bag, leg or abdomen, A4358
tract endoscope, C1747 ◀
tract implant, collagen, L8603
tract implant, synthetic, L8606
Urine
sensitivity study, P7001
system, K1006
tests, A4250
Urofollitropin, J3355
Urokinase, J3364, J3365
Ustekinumab, J3357, J3758
U-V lens, V2755

V
Vabra aspirator, A4480
Vaccination, administration
flublok, Q2033
hepatitis B, G0010
influenza virus, G0008
pneumococcal, G0009
Vaccine
administration, influenza, G0008
administration, pneumococcal, G0009
hepatitis B, administration, G0010
Vaginal
cancer, screening, G0101
cytopathologist, G0123
cytopathology, G0123, G0124, G0141–G0148
screening, cervical/vaginal, thin-layer, cytopathologist, G0123
screening, cervical/vaginal, thin-layer, physician interpretation, G0124
screening cytopathology smears, automated, G0141–G0148
Vancomycin HCl, J3370–J3372 ◀
Vaporizer, E0605
Vascular
catheter (appliances and supplies), A4300–A4306
disposable drug delivery system, >50 ml/hr, A4305
disposable drug delivery system, <50 ml/hr, A4306
implantable access catheter, external, A4300
implantable access total, catheter, A4301
graft material, synthetic, L8670
Vasoxyl, J3390
Vedolizumab, J3380
Vehicle, power-operated, K0800–K0899
Velaglucerase alfa, J3385
Venous pressure clamp, dialysis, A4918
Ventilator
battery, A4611–A4613
 home ventilator, any type, E0465, E0466
used with invasive interface (e.g., tracheostomy tube), E0465
used with non-invasive interface (e.g., mask, chest shell), E0466
moisture exchanger, disposable, A4483
Ventricular assist device, Q0478–Q0504, Q0506–Q0509
battery clips, electric or electric/pneumatic, replacement, Q0497
battery, lithium-ion, electric or electric/pneumatic, replacement, Q0506
battery, other than lithium-ion, electric or electric/pneumatic, replacement, Q0496
battery, pneumatic, replacement, Q0503
battery/power-pack charger, electric or electric/pneumatic, replacement, Q0495
belt/vest/bag, carry external components, replacement, Q0499
driver, replacement, Q0480
ejection, fraction, left, M1150 ◀
emergency hand pump, electric or electric/pneumatic, replacement, Q0494
emergency power source, electric, replacement, Q0490
emergency power source, electric/pneumatic, replacement, Q0491
emergency power supply cable, electric, replacement, Q0492
emergency power supply cable, electric/pneumatic, replacement, Q0493
filters, electric or electric/pneumatic, replacement, Q0500
holster, electric or electric/pneumatic, replacement, Q0498
leads (pneumatic/electrical), replacement, Q0487
microprocessor control unit, electric/pneumatic combination, replacement, Q0482
microprocessor control unit, pneumatic, replacement, Q0481
miscellaneous supply, external VAD, Q0507
miscellaneous supply, implanted device, Q0508
miscellaneous supply, implanted device, payment not made under Medicare Part A, Q0509
mobility cart, replacement, Q0502
monitor control cable, electric, replacement, Q0485
monitor control cable, electric/pneumatic, Q0486
monitor/display module, electric, replacement, Q0483
monitor/display module, electric/electric pneumatic, replacement, Q0484
power adapter, pneumatic, replacement, vehicle type, Q0504
power adapter, vehicle type, Q0478
power module, replacement, Q0479
power-pack base, electric, replacement, Q0488
power-pack base, electric/pneumatic, replacement, Q0489
shower cover, electric or electric/pneumatic, replacement, Q0501
Verteporfin, J3396
Vest, safety, wheelchair, E0980
Vinblastine sulfate, J9360
Vincristine sulfate, J9370, J9371
Vinorelbine tartrate, J9390
Vision service, V2020–V2799
bifocal, glass or plastic, V2200–V2299
contact lenses, V2500–V2599
frames, V2020–V2025
intraocular lenses, V2630–V2632
low-vision aids, V2600–V2615
miscellaneous, V2700–V2799
prosthetic eye, V2623–V2629
spectacle lenses, V2100–V2199
trifocal, glass or plastic, V2300–V2399
variable asphericity, V2410–V2499
Visit, emergency department, G0380–G0384
Visual, function, postoperative cataract surgery, G0915–G0918
Vitamin B-12 cyanocobalamin, J3420
Vitamin K, J3430
Voice
amplifier, L8510
prosthesis, L8511–L8514
Von Willebrand Factor Complex, human, J7179, J7183, J7187
Voriconazole, J3465
Vutrisiran, J0225 ◀

W
Waiver, T2012–T2050
assessment/plan of care development, T2024
case management, per month, T2022
day habilitation, per 15 minutes, T2021
day habilitation, per diem, T2020
habilitation, educational, per diem, T2012
habilitation, educational, per hour, T2013
habilitation, prevocational, per diem, T2014
habilitation, prevocational, per hour, T2015
habilitation, residential, 15 minutes, T2017
habilitation, residential, per diem, T2016
habilitation, supported employment, 15 minutes, T2019
habilitation, supported employment, per diem, T2018
targeted case management, per month, T2023
waiver services NOS, T2025
Walker, E0130–E0149
accessories, A4636, A4637
attachments, E0153–E0159
enclosed, four-sided frame, E0144
folding (pickup), E0135
folding, wheeled, E0143
heavy duty, multiple braking system, E0147
heavy duty, wheeled, rigid or folding, E0149
heavy duty, without wheels, E0148
rigid (pickup), E0130
rigid, wheeled, E0141
with trunk support, E0140
Walking splint, L4386
Washer, Gravlee jet, A4470
Water
dextrose, J7042, J7060, J7070
distilled (for nebulizer), A7018
pressure pad/mattress, E0187, E0198
purification system (ESRD), E1610, E1615
softening system (ESRD), E1625
sterile, A4714
WBC/CBC, G0306
Wedges, shoe, L3340–L3420
Wellness, promoting, M0005 ◀
Wellness visit; annual, G0438, G0439
Wet mount, Q0111
Wheel attachment, rigid pickup walker, E0155
Wheelchair, E0950–E1298, K0001–K0108, K0801–K0899
accessories, E0192, E0950–E1030, E1065–E1069, E2211–E2230, E2300–E2399,
E2626–E2633
amputee, E1170–E1200
back, fully reclining, manual, E1226
component or accessory, not otherwise specified, K0108
cushions, E2601–E2625
custom manual wheelchair base, K0008
custom motorized/power base, K0013
dynamic positioning hardware for back, E2398
foot box, E0954
heavy duty, E1280–E1298, K0006, K0007, K0801–K0886
lateral thigh or knee support, E0953
lightweight, E1087–E1090, E1240–E1270
 narrowing device, E0969
power add-on, E0983–E0984
reclining, fully, E1014, E1050–E1070, E1100–E1110
semi-reclining, E1100–E1110
shock absorber, E1015–E1018
specially sized, E1220, E1230
standard, E1130, K0001
stump support system, K0551
tire, E0999
transfer board or device, E0705
tray, K0107
van, non-emergency, A0130
youth, E1091
WHFO with inflatable air chamber, L3807
Whirlpool equipment, E1300–E1310
Whirlpool tub, walk-in, portable, K1003
WHO, wrist extension, L3914
Wig, A9282
Wipes, A4245, A4247
Wound
cleanser, A6260
closure, adhesive, G0168
cover
alginate dressing, A6196–A6198
collagen dressing, A6020–A6024
foam dressing, A6209–A6214
hydrocolloid dressing, A6234–A6239
hydrogel dressing, A6242–A6247
non-contact wound warming cover, and accessory, E0231–E0232
specialty absorptive dressing, A2001–A2010, A2015–2018, A6251–A6256 ◀
filler
alginate dressing, A6199
collagen based, A6010
foam dressing, A6215
hydrocolloid dressing, A6240–A6241
hydrogel dressing, A6248
not elsewhere classified, A6261–A6262
Woundfix, Woundfix Plus, Q4217
matrix, Q4114
pouch, A6154
therapy, negative, pressure, pump, E2402
 wound suction, A9272, K0743
Wrapping, fabric, abdominal aneurysm, M0301
Wrist
disarticulation prosthesis, L6050, L6055
electronic wrist rotator, L7259
hand/finger orthosis (WHFO), E1805, E1825, L3800–L3954

X
Xenon Xe 133, A9558
Xipere, J3299 ◀
X-ray
equipment, portable, Q0092, R0070, R0075
single, energy, absorptiometry (SEXA), G0130
transport, R0070–R0076
Xylocaine HCl, J2000

Y
Yttrium Y-90 ibritumomab, A9543

Z
Ziconotide, J2278
Zidovudine, J3485
Ziprasidone mesylate, J3486
Zoledronic acid, J3489
Zynlonta, J9359 ◀

◀ New Revised ✔ Reinstated deleted Deleted

TABLE OF DRUGS
IA Intra-arterial administration
IU International unit
IV Intravenous administration
IM Intramuscular administration
IT Intrathecal
SC Subcutaneous administration
INH Administration by inhaled solution
VAR Various routes of administration
OTH Other routes of administration
ORAL Administered orally

Intravenous administration includes all methods, such as gravity infusion, injections, and
timed pushes. The “VAR” posting denotes various routes of administration and is used for
drugs that are commonly administered into joints, cavities, tissues, or topical applications, in
addition to other parenteral administrations. Listings posted with “OTH” indicate other
administration methods, such as suppositories or catheter injections.

Blue typeface terms are added by publisher.

METHOD OF
DRUG NAME DOSAGE ADMINISTRATION HCPCS CODE

A
Abatacept 10 mg IV J0129
Abbokinase 5,000 IU IV J3364
vial
250,000 IV J3365
IU vial
Abbokinase, Open Cath 5,000 IU IV J3364
vial
Abciximab 10 mg IV J0130
Abelcet 10 mg IV J0287-J0289
Abilify Maintena 1 mg J0401
ABLC 50 mg IV J0285
AbobotulinumtoxinA 5 units IM J0586
Abraxane 1 mg J9264
Accuneb 1 mg J7613
Acetadote 100 mg J0132
Acetaminophen 10 mg IV J0131
Acetazolamide sodium up to 500 IM, IV J1120
mg
Acetylcysteine
injection 100 mg IV J0132
unit dose form per gram INH J7604,
J7608
Achromycin up to 250 IM, IV J0120
mg
Actemra 1 mg J3262
ACTH up to 40 IV, IM, SC J0800
units
Acthar up to 40 IV, IM, SC J0800
units
Acthib J3490
Acthrel 1 mcg J0795
Actimmune 3 million SC J9216
units
Activase 1 mg IV J2997
Acyclovir 5 mg J0133
J8499
Adagen 25 IU J2504
Adalimumab 20 mg SC J0135
Adcetris 1 mg IV J9042
Adenocard 1 mg IV J0153
Adenoscan 1 mg IV J0153
Adenosine 1 mg IV J0153
Ado-trastuzumab Emtansine 1 mg IV J9354
Adrenalin Chloride up to 1 ml SC, IM J0171
ampule
Adrenalin, epinephrine 0.1 mg SC, IM J0171
Adriamycin, PFS, RDF 10 mg IV J9000
Adrucil 500 mg IV J9190
Aduhelm 2 mg IV J0172
Advate per IU J7192
Afamelanotide implant 1 mg IV J7352
Aflibercept 1 mg OTH J0178
Agalsidase beta 1 mg IV J0180
Aggrastat 0.25 mg IM, IV J3246
A-hydrocort up to 50 IV, IM, SC J1710
mg
up to 100 J1720
mg
Akineton per 5 mg IM, IV J0190
Akynzeo 300 mg J8655
and 0.5
mg
Alatrofloxacin mesylate, injection 100 mg IV J0200
Albumin P9041,
P9045,
P9046,
P9047
Albuterol 0.5 mg INH J7620
concentrated form 1 mg INH J7610, J7611
 unit dose form 1 mg INH J7609,
J7613
Aldesleukin per single IM, IV J9015
use vial
Aldomet up to 250 IV J0210
mg
Aldurazyme 0.1 mg J1931
Alefacept 0.5 mg IM, IV J0215
Alemtuzumab 1 mg J0202
Alferon N 250,000 IM J9215
IU
Alglucerase per 10 IV J0205
units
Alglucosidase alfa 10 mg IV J0220,
J0221
Alimta 10 mg J9305
Alkaban-AQ 1 mg IV J9360
Alkeran 2 mg ORAL J8600
50 mg IV J9245
AlloDerm per square Q4116
centimeter
AlloSkin per square Q4115
centimeter
Aloxi 25 mcg J2469
Alpha 1-proteinase inhibitor, 10 mg IV J0256,
human J0257
Alphanate J7186
AlphaNine SD per IU J7193
Alprolix per IU J7201
Alprostadil
 injection 1.25 mcg OTH J0270

urethral suppository each OTH J0275

Alteplase recombinant 1 mg IV J2997
Alupent per 10 mg INH J7667,
J7668
noncompounded, unit dose 10 mg INH J7669
unit dose 10 mg INH J7670
AmBisome 10 mg IV J0289
Amcort per 5 mg IM J3302
A-methaPred up to 40 IM, IV J2920
mg
up to 125 IM, IV J2930
mg
Amgen 1 mcg SC J9212
Amifostine 500 mg IV J0207
Amikacin sulfate 100 mg IM, IV J0278
Aminocaproic Acid J3490
Aminolevulinic acid HCl unit dose OTH J7308
(354 mg)
Aminolevulinic acid HCl 10% Gel 10 mg OTH J7345
Aminolevulinate 1g OTH J7309
Aminophylline/Aminophyllin up to 250 IV J0280
mg
Amiodarone HCl 30 mg IV J0282
Amitriptyline HCl up to 20 IM J1320
mg
Amobarbital up to 125 IM, IV J0300
mg
Amphadase 1 ml J3470
Amphocin 50 mg IV J0285
Amphotericin B 50 mg IV J0285

Amphotericin B, lipid complex 10 mg IV J0287-J0289

Ampicillin
sodium up to 500 IM, IV J0290
mg
sodium/sulbactam sodium per 1.5 g IM, IV J0295
Amygdalin J3570
Amytal up to 125 IM, IV J0300
mg
Anabolin LA 100 up to 50 IM J2320
mg
Anadulafungin 1 mg IV J0348
Anascorp up to 120 IV J0716
mg
Anastrozole 1 mg J8999
Ancef 500 mg IV, IM J0690
Andrest 90-4 1 mg IM J3121
Andro-Cyp 1 mg J1071
Andro-Cyp 200 1 mg J1071
Andro L.A. 200 1 mg IM J3121
Andro-Estro 90-4 1 mg IM J3121
Andro/Fem 1 mg J1071
Androgyn L.A. 1 mg IM J3121
Androlone-50 up to 50 J2320
mg
Androlone-D 100 up to 50 IM J2320
mg
Andronaq-50 up to 50 IM J3140
mg

Andronaq-LA 1 mg J1071
Andronate-100 1 mg J1071
Andronate-200 1 mg J1071
Andropository 100 1 mg IM J3121
Andryl 200 1 mg IM J3121
Anectine up to 20 IM, IV J0330
mg
Anergan 25 up to 50 IM, IV J2550
mg
12.5 mg ORAL Q0169
Anergan 50 up to 50 IM, IV J2550
mg
12.5 mg ORAL Q0169
Angiomax 1 mg J0583
Anidulafungin 1 mg IV J0348
Anistreplase 30 units IV J0350
Antiflex up to 60 IM, IV J2360
mg
Anti-Inhibitor per IU IV J7198
Antispas up to 20 IM J0500
mg
Antithrombin III (human) per IU IV J7197
Antithrombin recombinant 50 IU IV J7196
Anzemet 10 mg IV J1260
50 mg ORAL S0174
100 mg ORAL Q0180
Apidra Solostar per 50 J1817
units
A.P.L. per 1,000 IM J0725
USP units
Apligraf per square Q4101
centimeter
Apomorphine Hydrochloride 1 mg SC J0364
Aprepitant 1 mg IV J0185
Aprepitant 5 mg ORAL J8501
Apresoline up to 20 IV, IM J0360
mg
Aprotinin 10,000 kiu J0365
AquaMEPHYTON per 1 mg IM, SC, IV J3430
Aralast 10 mg IV J0256
Aralen up to 250 IM J0390
mg
Aramine per 10 mg IV, IM, SC J0380
Aranesp
ESRD use 1 mcg J0882
Non-ESRD use 1 mcg J0881
Arbutamine 1 mg IV J0395
Arcalyst 1 mg J2793
Aredia per 30 mg IV J2430
Arfonad, see Trimethaphan
camsylate
Arformoterol tartrate 15 mcg INH J7605
Argatroban
(for ESRD use) 1 mg IV J0884, ◀
J0892,
J0899
(for non-ESRD use) 1 mg IV J0883, ◀
J0891,
J0898
Aridol 25% in 50 IV J2150
 ml
5 mg INH J7665
Arimidex J8999
Aripiprazole 0.25 mg IM J0400
Aripiprazole, extended release 1 mg IV J0401
Aripiprazole lauroxil 1 mg IV J1942
Aripiprazole lauroxil (aristada) 1 mg IV J1944
Aripiprazole lauroxil (aristada 1 mg IV J1943
initio)
Aristocort Forte per 5 mg IM J3302
Aristocort Intralesional per 5 mg IM J3302
Aristospan Intra-Articular per 5 mg VAR J3303
Aristospan Intralesional per 5 mg VAR J3303
Arixtra per 0.5 m J1652
Aromasin J8999
Arranon 50 mg J9261
Arrestin up to 200 IM J3250
mg
250 mg ORAL Q0173
Arsenic trioxide 1 mg IV J9017
Arzerra 10 mg J9302
Asparaginase 1,000 IV, IM J9019
units
10,000 IV, IM J9020
units
Astagraf XL 0.1 mg J7508
Astramorph PF up to 10 IM, IV, SC J2270
mg
Atezolizumab 10 mg IV J9022
Atgam 250 mg IV J7504

Ativan 2 mg IM, IV J2060

Atropine
concentrated form per mg INH J7635
unit dose form per mg INH J7636
sulfate 0.01 mg IV, IM, SC J0461,
J7636
Atrovent, unit dose form per mg INH J7644,
J7645
ATryn 50 IU IV J7196
Aurothioglucose up to 50 IM J2910
mg
Autologous cultured chondrocytes OTH J7330
implant
Autoplex T per IU IV J7198,
J7199
AUVI-Q 0.15 mg J0171
Avastin 10 mg J9035
Avelox 100 mg J2280
Avelumab 10 mg IV J9023
Avonex 30 mcg IM J1826
1 mcg IM Q3027
1 mcg SC Q3028
Azacitidine 1 mg SC J9025
Azasan 50 mg J7500
Azathioprine 50 mg ORAL J7500
Azathioprine, parenteral 100 mg IV J7501
Azithromycin, dihydrate 1 gram ORAL Q0144
Azithromycin, injection 500 mg IV J0456
B
Baciim J3490
Bacitracin J3490
Baclofen 10 mg IT J0475
Baclofen for intrathecal trial 50 mcg OTH J0476
Bactocill up to 250 IM, IV J2700
mg
BAL in oil per 100 IM J0470
mg
Bamlan and etesev IV M0245
Bamlanivimab and etesevima 2100 mg IV Q0245
Banflex up to 60 IV, IM J2360
mg
Basiliximab 20 mg J0480
BCG live intravesical instillation 1 mg OTH J9030
Bebulin per IU J7194
Beclomethasone inhalation per mg INH J7622
solution, unit dose form
Belantamab mafodotin-blmf 0.5 mg IV J9037
Belatacept 1 mg IV J0485
Beleodaq 10 mg J9032
Belimumab 10 mg IV J0490
Belinostat 10 mg IV J9032
Bena-D 10 up to 50 IV, IM J1200
mg
Bena-D 50 up to 50 IV, IM J1200
mg
Benadryl up to 50 IV, IM J1200
mg
Benahist 10 up to 50 IV, IM J1200
 mg
Benahist 50 up to 50 IV, IM J1200
mg
Ben-Allergin-50 up to 50 IV, IM J1200
mg
50 mg ORAL Q0163
Bendamustine HCl
Bendeka 1 mg IV J9034
Treanda 1 mg IV J9033
Bendamustine HCl 1 mg IV J9036
(Belrapzo/bendamustine)
Benefix per IU IV J7195
Benlysta 10 mg J0490
Benoject-10 up to 50 IV, IM J1200
mg
Benoject-50 up to 50 IV, IM J1200
mg
Benralizumab 1 mg IV J0517
Bentyl up to 20 IM J0500
mg
Benzocaine J3490
Benztropine mesylate per 1 mg IM, IV J0515
Berinert 10 units J0597
Berubigen up to IM, SC J3420
1,000 mcg
Beta amyloid per study OTH A9599
dose
Betalin 12 up to IM, SC J3420
1,000 mcg
Betameth per 3 mg IM, IV J0702
Betamethasone Acetate J3490
Betamethasone Acetate & per 3 mg IM J0702
Betamethasone Sodium Phosphate
Betamethasone inhalation solution, per mg INH J7624
unit dose form
Betaseron 0.25 mg SC J1830
Bethanechol chloride up to 5 mg SC J0520
Bethkis 300 mg J7682
Bevacizumab 10 mg IV J9035
Bevacizumab-awwb 10 mg IV Q5107
Bevacizumab-bvzr (Zirabev) 10 mg IV Q5118
Bezlotoxumab 10 mg IV J0565
Bicillin C-R 100,000 J0558
units
Bicillin C-R 900/300 100,000 IM J0558,
units J0561
Bicillin L-A 100,000 IM J0561
units
BiCNU 100 mg IV J9050
Biperiden lactate per 5 mg IM, IV J0190
Bitolterol mesylate
concentrated form per mg INH J7628
unit dose form per mg INH J7629
Bivalirudin 1 mg IV J0583
Blenoxane 15 units IM, IV, SC J9040
Bleomycin sulfate 15 units IM, IV, SC J9040
Blinatumomab 1 IV J9039
microgram
Blincyto 1 mcg J9039
Boniva 1 mg J1740
Bortezomib 0.1 mg IV J9041
Bortezomib, not otherwise 0.1 mg J9044 ◀
specified J9046,
J9048,
J9049
Botox 1 unit J0585
Bravelle 75 IU J3355
Brentuximab Vedotin 1 mg IV J9042
Brethine
concentrated form per 1 mg INH J7680
unit dose per 1 mg INH J7681
up to 1 mg SC, IV J3105
Bricanyl Subcutaneous up to 1 mg SC, IV J3105
Brompheniramine maleate per 10 mg IM, SC, IV J0945
Bronkephrine, see
Ethylnorepinephrine HCl
Bronkosol
concentrated form per mg INH J7647,
J7648
unit dose form per mg INH J7649,
J7650
Brovana J7605
Budesonide inhalation solution
concentrated form 0.25 mg INH J7633,
J7634
unit dose form 0.5 mg INH J7626,
J7627
Bumetanide J3490
Bupivacaine J3490
Buprenex 0.3 mg J0592
Buprenorphine Hydrochloride 0.1 mg IM J0592
Buprenorphine/Naloxone 1 mg ORAL J0571

< = 3 mg ORAL J0572

> 3 mg but ORAL J0573
< = 6 mg
> 6 mg but ORAL J0574
< = 10 mg
> 10 mg ORAL J0575
Buprenorphine extended release < = 100 ORAL Q9991
mg
> 100 mg ORAL Q9992
Burosumab-twza 1 mg IV J05894
Busulfan 1 mg IV J0594
2 mg ORAL J8510
Butorphanol tartrate 1 mg J0595
C
C1 Esterase Inhibitor 10 units IV J0596-J0599
Cabazitaxel 1 mg IV J9043
Cabergoline 0.25 mg ORAL J8515
Cabote Rilpivir 2 mg/3 mg IV J0741
Cabotegravir 1 mg IM J0739 ◀
Cafcit 5 mg IV J0706
Caffeine citrate 5 mg IV J0706
Caine-1 10 mg IV J2001
Caine-2 10 mg IV J2001
Calaspargase pegol-mknl 10 units IV J9118
Calcijex 0.1 mcg IM J0636
Calcimar up to 400 SC, IM J0630
units

Calcitonin-salmon up to 400 SC, IM J0630

 units
Calcitriol 0.1 mcg IM J0636
Calcitrol J8499
Calcium Disodium Versenate up to IV, SC, IM J0600
1,000 mg
Calcium gluconate per 10 ml IV J0610
Calcium glycerophosphate and per 10 ml IM, SC J0620
calcium lactate
Caldolor 100 mg IV J1741
Calphosan per 10 ml IM, SC J0620
Camcevi 1 mg IV J1952
Camptosar 20 mg IV J9206
Canakinumab 1 mg SC J0638
Cancidas 5 mg J0637
Capecitabine 150 mg ORAL J8520
500 mg ORAL J8521
Capsaicin patch per sq cm OTH J7336
Carbidopa 5 mg/levodopa 20 mg IV J7340
enteral suspension
Carbocaine per 10 ml VAR J0670
Carbocaine with Neo-Cobefrin per 10 ml VAR J0670
Carboplatin 50 mg IV J9045
Carfilzomib 1 mg IV J9047
Carimune 500 mg J1566
Carmustine 100 mg IV J9050
Carnitor per 1 g IV J1955
Carticel J7330

Casimersen 10 mg IV J1426
Caspofungin acetate 5 mg IV J0637
Cathflo Activase 1 mg J2997
Caverject per 1.25 J0270
mcg
Cayston 500 mg S0073
Cefadyl up to 1 g IV, IM J0710
Cefazolin sodium 500 mg IV, IM J0690
Cefepime hydrochloride 500 mg IV J0692
Cefiderocol 10 mg IV J0699
Cefizox per 500 IM, IV J0715
mg
Cefotaxime sodium per 1 g IV, IM J0698
Cefotetan J3490
Cefoxitin sodium 1g IV, IM J0694
Ceftaroline fosamil 1 mg IV J0712
Ceftazidime per 500 IM, IV J0713
mg
Ceftazidime and avibactam 0.5 IV J0714
g/0.125 g
Ceftizoxime sodium per 500 IV, IM J0715
mg
Ceftolozane 50 mg and IV J0695
Tazobactam 25 mg
Ceftriaxone sodium per 250 IV, IM J0696
mg
Cefuroxime sodium, sterile per 750 IM, IV J0697
mg
Celestone Soluspan per 3 mg IM J0702
CellCept 250 mg ORAL J7517
Cel-U-Jec per 4 mg IM, IV Q0511
Cenacort A-40 1 mg J3300
per 10 mg IM J3301
Cenacort Forte per 5 mg IM J3302
Centruroides Immune F(ab) up to 120 IV J0716
mg
Cephalothin sodium up to 1 g IM, IV J1890
Cephapirin sodium up to 1 g IV, IM J0710
Ceprotin 10 IU J2724
Ceredase per 10 IV J0205
units
Cerezyme 10 units J1786
Cerliponase alfa 1 mg IV J0567
Certolizumab pegol 1 mg SC J0717
Cerubidine 10 mg IV J9150
Cetirizine hydrochloride 0.5 mg IM J1201
Cetuximab 10 mg IV J9055
Chealamide per 150 IV J3520
mg
Chirhostim 1 mcg IV J2850
Chloramphenicol Sodium up to 1 g IV J0720
Succinate
Chlordiazepoxide HCl up to 100 IM, IV J1990
mg
Chloromycetin Sodium Succinate up to 1 g IV J0720
Chloroprocaine HCl per 30 ml VAR J2400 ◀
1mg J2401,
J2402
Chloroquine HCl up to 250 IM J0390
mg
Chlorothiazide sodium per 500 IV J1205
mg
Chlorpromazine 5 mg ORAL Q0161
Chlorpromazine HCl up to 50 IM, IV J3230
mg
Cholografin Meglumine per ml Q9961
Chorex-5 per 1,000 IM J0725
USP units
Chorex-10 per 1,000 IM J0725
USP units
Chorignon per 1,000 IM J0725
USP units
Chorionic Gonadotropin per 1,000 IM J0725
USP units
Choron 10 per 1,000 IM J0725
USP units
Cidofovir 375 mg IV J0740
Cilastatin sodium, imipenem per 250 IV, IM J0743
mg
Cimzia 1 mg SC J0717
Cinacalcet 1 mg ORAL J0604
Cinryze 10 units J0598
Cipro IV 200 mg IV J0706
Ciprofloxacin 200 mg IV J0706
otic suspension 6 mg OTH J7342
J3490
Cisplatin, powder or solution per 10 mg IV J9060
Cladribine per mg IV J9065
Claforan per 1 gm IM, IV J0698
Cleocin Phosphate J3490
Clindamycin J3490
Clofarabine 1 mg IV J9027
Clolar 1 mg J9027

Clonidine Hydrochloride 1 mg Epidural J0735

Coagulation factor Xa 10 mg J7169
(recombinant), inactivated-zhzo
(Andexxa)
Cobex up to IM, SC J3420
1,000 mcg
Codeine phosphate per 30 mg IM, IV, SC J0745
Codimal-A per 10 mg IM, SC, IV J0945
Cogentin per 1 mg IM, IV J0515
Colistimethate sodium up to 150 IM, IV J0770
mg
Collagenase, Clostridium 0.01 mg OTH J0775
Histolyticum
Coly-Mycin M up to 150 IM, IV J0770
mg
Compa-Z up to 10 IM, IV J0780
mg
Copanlisib 1 mg IV J9057
Compazine up to 10 IM, IV J0780
mg
5 mg ORAL Q0164
J8498
Compounded drug, not otherwise J7999
classified
Compro J8498
Conray per ml Q9961
Conray 30 per ml Q9958
Conray 43 per ml Q9960
Copaxone 20 mg J1595
Cophene-B per 10 mg IM, SC, IV J0945
Copper contraceptive, intrauterine OTH J7300
Cordarone 30 mg IV J0282
Corgonject-5 per 1,000 IM J0725
USP units
Corifact 1 IU J7180
Corticorelin ovine triflutate 1 mcg J0795
Corticotropin up to 40 IV, IM, SC J0800
units
Cortisone Acetate Micronized J3490
Cortrosyn per 0.25 IM, IV J0835
mg
Corvert 1 mg J1742
Cosmegen 0.5 mg IV J9120
Cosyntropin per 0.25 IM, IV J0833,
mg J0834
Cotranzine up to 10 IM, IV J0780
mg
Crizanlizumab-tmca IV J0791
Crofab up to 1 J0840
gram
Cromolyn Sodium J8499
Cromolyn sodium, unit dose form per 10 mg INH J7631,
J7632
Crotalidae immune f(ab’)2 (equine) 120 mg IV J0841
Crotalidae Polyvalent Immune Fab up to 1 IV J0840
gram
Crysticillin 600 A.S. up to IM, IV J2510
600,000
units
Cubicin 1 mg J0878

Cutaquig 100 mg IM J1551 ◀

Cuvitru J7799
Cyclophosphamide 100 mg IV J9070
oral 25 mg ORAL J8530
Cyclosporine 25 mg ORAL J7515
100 mg ORAL J7502
parenteral 250 mg IV J7516
Cymetra 1 cc Q4112
Cyramza 5 mg J9308
Cysto-Conray II per ml Q9958
Cystografin per ml Q9958
Cytarabine 100 mg SC, IV J9100
Cytarabine liposome 10 mg IT J9098
CytoGam per vial J0850
Cytomegalovirus immune globulin per vial IV J0850
intravenous (human)
Cytosar-U 100 mg SC, IV J9100
Cytovene 500 mg IV J1570
Cytoxan 100 mg IV J8530,
J9070
D
D-5-W, infusion 1000 cc IV J7070
Dacarbazine 100 mg IV J9130
Daclizumab 25 mg IV J7513
Dacogen 1 mg J0894
Dactinomycin 0.5 mg IV J9120
Dalalone 1 mg IM, IV, OTH J1100
Dalalone L.A. 1 mg IM J1094
Dalbavancin 5 mg IV J0875
Dalteparin sodium per 2500 SC J1645
IU
Daptomycin 1 mg IV J0877, ◀
J0878
Daratumumab 10 mg IV J9145
Darbepoetin Alfa 1 mcg IV, SC J0881,
J0882
Darzalex 10 mg J9145
Daunorubicin citrate, liposomal 10 mg IV J9151
formulation
Daunorubicin HCl 10 mg IV J9150
Daunoxome 10 mg IV J9151
DDAVP 1 mcg IV, SC J2597
Decadron 1 mg IM, IV, OTH J1100
0.25 mg J8540
Decadron Phosphate 1 mg IM, IV, OTH J1100
Decadron-LA 1 mg IM J1094
Deca-Durabolin up to 50 IM J2320
mg
Decaject 1 mg IM, IV, OTH J1100
Decaject-L.A. 1 mg IM J1094
Decitabine 1 mg IV J0893, ◀
J0894
Decolone-50 up to 50 IM J2320
mg
Decolone-100 up to 50 IM J2320
mg
De-Comberol 1 mg J1071
Deferoxamine mesylate 500 mg IM, SC, IV J0895
Definity per ml J3490,
Q9957
Degarelix 1 mg SC J9155
Dehist per 10 mg IM, SC, IV J0945
Deladumone 1 mg IM J3121
Deladumone OB 1 mg IM J3121
Delatest 1 mg IM J3121
Delatestadiol 1 mg IM J3121
Delatestryl 1 mg IM J3121
Delestrogen up to 10 IM J1380
mg
Delta-Cortef 5 mg ORAL J7510
Demadex 10 mg/ml IV J3265
Demerol HCl per 100 IM, IV, SC J2175
mg
Denileukin diftitox 300 mcg IV J9160
Denosumab 1 mg SC J0897
Deoxycholic acid 1 mg IM J0591
DepAndro 100 1 mg J1071
DepAndro 200 1 mg J1071
DepAndrogyn 1 mg J1071
DepGynogen up to 5 mg IM J1000
DepMedalone 40 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
DepMedalone 80 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
DepoCyt 10 mg J9098
Depo-estradiol cypionate up to 5 mg IM J1000
Depogen up to 5 mg IM J1000
Depoject 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
Depo-Medrol 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
Depopred-40 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
Depopred-80 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
Depo-Provera Contraceptive 1 mg J1050
Depotest 1 mg J1071
Depo-Testadiol 1 mg J1071
Depo-Testosterone 1 mg J1071
Depotestrogen 1 mg J1071
Dermagraft per square Q4106
centimeter
Desferal Mesylate 500 mg IM, SC, IV J0895
Desmopressin acetate 1 mcg IV, SC J2597
Dexacen-4 1 mg IM, IV, OTH J1100
Dexacen LA-8 1 mg IM J1094
Dexamethasone
 concentrated form per mg INH J7637
intravitreal implant 0.1 mg OTH J7312
lacrimal ophthalmic insert 0.1 mg OTH J1096
unit form per mg INH J7638
oral 0.25 mg ORAL J8540
acetate 1 mg IM J1094
sodium phosphate 1 mg IM, IV, OTH J1100
Dexasone 1 mg IM, IV, OTH J1100
Dexasone L.A. 1 mg IM J1094
Dexferrum 50 mg J1750
Dexone 0.25 mg ORAL J8540
1 mg IM, IV, OTH J1100
Dexone LA 1 mg IM J1094
Dexpak 0.25 mg ORAL J8540
Dexrazoxane hydrochloride 250 mg IV J1190
Dextran 40 500 ml IV J7100
Dextran 75 500 ml IV J7110
Dextrose 5%/normal saline 500 ml = 1 IV J7042
solution unit
Dextrose/water (5%) 500 ml = 1 IV J7060
unit
D.H.E. 45 per 1 mg J1110
Diamox up to 500 IM, IV J1120
mg
Diazepam up to 5 mg IM, IV J3360
Diazoxide up to 300 IV J1730
mg
Dibent up to 20 IM J0500
mg
Diclofenac sodium 37.5 IV J1130
Dicyclomine HCl up to 20 IM J0500
mg

Didronel per 300 IV J1436

mg
Diethylstilbestrol diphosphate 250 mg IV J9165
Diflucan 200 mg IV J1450
DigiFab per vial J1162
Digoxin up to 0.5 IM, IV J1160
mg
Digoxin immune fab (ovine) per vial J1162
Dihydrex up to 50 IV, IM J1200
mg
50 mg ORAL Q0163
Dihydroergotamine mesylate per 1 mg IM, IV J1110
Dilantin per 50 mg IM, IV J1165
Dilaudid up to 4 mg SC, IM, IV J1170
250 mg OTH S0092
Dilocaine 10 mg IV J2001
Dilomine up to 20 IM J0500
mg
Dilor up to 500 IM J1180
mg
Dimenhydrinate up to 50 IM, IV J1240
mg
Dimercaprol per 100 IM J0470
mg
Dimethyl sulfoxide 50%, 50 OTH J1212
ml
Dinate up to 50 IM, IV J1240
mg
Dioval up to 10 IM J1380
 mg

Dioval 40 up to 10 IM J1380
mg
Dioval XX up to 10 IM J1380
mg
Diphenacen-50 up to 50 IV, IM J1200
mg
50 mg ORAL Q0163
Diphenhydramine HCl
IV up to 50 IV, IM J1200
mg
oral 50 mg ORAL Q0163
Diprivan 10 mg J2704
J3490
Dipyridamole per 10 mg IV J1245
Disotate per 150 IV J3520
mg
Di-Spaz up to 20 IM J0500
mg
Ditate-DS 1 mg IM J3121
Diuril Sodium per 500 IV J1205
mg
D-Med 80 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
DMSO, Dimethyl sulfoxide 50% 50 ml OTH J1212
Dobutamine HCl per 250 IV J1250
mg
Dobutrex per 250 IV J1250
mg
Docefrez 1 mg J9171

Docetaxel 20 mg IV J9170
Dolasetron mesylate
injection 10 mg IV J1260
tablets 100 mg ORAL Q0180
Dolophine HCl up to 10 IM, SC J1230
mg
Dommanate up to 50 IM, IV J1240
mg
Donbax 10 mg J1267
Dopamine 40 mg J1265
Dopamine HCl 40 mg J1265
Doribax 10 mg J1267
Doripenem 10 mg IV J1267
Dornase alpha, unit dose form per mg INH J7639
Dotarem 0.1 ml A9575
Doxercalciferol 1 mcg IV J1270
Doxil 10 mg IV J9000,
Q2050
Doxorubicin HCL 10 mg IV J9000
Doxy 100 mg J3490
Dramamine up to 50 IM, IV J1240
mg
Dramanate up to 50 IM, IV J1240
mg
Dramilin up to 50 IM, IV J1240
mg
Dramocen up to 50 IM, IV J1240
mg
Dramoject up to 50 IM, IV J1240
mg

Dronabinol 2.5 mg ORAL Q0167

Droperidol up to 5 mg IM, IV J1790
Droperidol and fentanyl citrate up to 2 ml IM, IV J1810
ampule
Droxia ORAL J8999
Drug administered through a INH J3535
metered dose inhaler
DTIC-Dome 100 mg IV J9130
Dua-Gen L.A. 1 mg IM J3121
DuoNeb up to 2.5 J7620
mg
Duopa 20 ml J7340
Duoval P.A. 1 mg IM J3121
Durabolin up to 50 IM J2320
mg
Duracillin A.S. up to IM, IV J2510
600,000
units
Duraclon 1 mg Epidural J0735
Dura-Estrin up to 5 mg IM J1000
Duragen-10 up to 10 IM J1380
mg
Duragen-20 up to 10 IM J1380
mg
Duragen-40 up to 10 IM J1380
mg
Duralone-40 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
Duralone-80 20 mg IM J1020
40 mg IM J1030

80 mg IM J1040
Duralutin, see
Hydroxyprogesterone Caproate
Duramorph up to 10 IM, IV, SC J2270,
mg J2274
Duratest-100 1 mg J1071
Duratest-200 1 mg J1071
Duratestrin 1 mg J1071
Durathate-200 1 mg IM J3121
Durvalumab 10 mg IV J9173
Dymenate up to 50 IM, IV J1240
mg
Dyphylline up to 500 IM J1180
mg
Dysport 5 units J0586
Dalvance 5 mg J0875
E
Ecallantide 1 mg SC J1290
Eculizumab 10 mg IV J1300
Edaravone 1 mg IV J1301
Edetate calcium disodium up to IV, SC, IM J0600
1,000 mg
Edetate disodium per 150 IV J3520
mg
Efgartigimod 2 mg IM J9332 ◀
Elaprase 1 mg J1743
Elavil up to 20 IM J1320
 mg
Elelyso 10 units J3060

Eligard 7.5 mg J9217

Elitek 0.5 mg J2783
Ellence 2 mg J9178
Elliotts B solution 1 ml OTH J9175
Eloctate per IU J7205
Elosulfase alfa 1 mg IV J1322
Elotuzumab 1 mg IV J9176
Eloxatin 0.5 mg J9263
Elspar 10,000 IV, IM J9020
units
Emapalunab-lzsg 1 mg IV J9210
Emend J1453,
J8501
Emete-Con, see Benzquinamide
Eminase 30 units IV J0350
Empliciti 1 mg J9176
Enbrel 25 mg IM, IV J1438
Endrate ethylenediamine-tetra- per 150 IV J3520
acetic acid mg
Enfortumab vedotin-ejfv 0.25 mg IM J9177
Enfuvirtide 1 mg SC J1324
Engerix-B J3490
Enovil up to 20 IM J1320
mg
Enoxaparin sodium 10 mg SC J1650
Entyvio J3380
Eovist 1 ml A9581

Epinephrine J7799
Epinephrine, adrenalin 0.1 mg SC, IM J0171
Epirubicin hydrochloride 2 mg J9178
Epoetin alfa, ESRD use 100 units IV, SC Q4081
Epoetin alfa, non-ESRD use 1000 units IV J0885
Epoetin alfa-epbx (Retacrit) ESRD 100 units IV Q5105
use
Epoetin alfa-epbx (Retacrit) non- 1000 units IV Q5106
ESRD use
Epoetin beta, ESRD use 1 mcg IV J0887
Epoetin beta, non-ESRD use 1 mcg IV J0888
Epogen 1,000 J0885
units
Q4081
Epoprostenol 0.5 mg IV J1325
Eptifibatide, injection 5 mg IM, IV J1327
Eravacycline 1 mg IV J0122
Eraxis 1 mg IV J0348
Erbitux 10 mg J9055
Ergonovine maleate up to 0.2 IM, IV J1330
mg
Eribulin mesylate 0.1 mg IV J9179
Erivedge 150 mg J8999
Ertapenem sodium 500 mg IM, IV J1335
Erwinase 1,000 IV, IM J9019
units
10,000 IV, IM J9020
units
Erythromycin lactobionate 500 mg IV J1364
Estra-D up to 5 mg IM J1000
Estradiol
L.A. up to 10 IM J1380
mg
L.A. 20 up to 10 IM J1380
mg
L.A. 40 up to 10 IM J1380
mg
Estradiol cypionate up to 5 mg IM J1000
Estradiol valerate up to 10 IM J1380
mg
Estra-L 20 up to 10 IM J1380
mg
Estra-L 40 up to 10 IM J1380
mg
Estra-Testrin 1 mg IM J3121
Estro-Cyp up to 5 mg IM J1000
Estrogen, conjugated per 25 mg IV, IM J1410
Estroject L.A. up to 5 mg IM J1000
Estrone per 1 mg IM J1435
Estrone 5 per 1 mg IM J1435
Estrone Aqueous per 1 mg IM J1435
Estronol per 1 mg IM J1435
Estronol-L.A. up to 5 mg IM J1000
Etanercept, injection 25 mg IM, IV J1438
Etelcalcetide 0.1 mg IV Q4078
Eteplirsen 10 mg IV J1428
Ethamolin 100 mg J1430
Ethanolamine 100 mg J1430,
J3490
Ethyol 500 mg IV J0207

Etidronate disodium per 300 IV J1436

mg
Etonogestrel implant J7307
Etopophos 10 mg IV J9181
Etoposide 10 mg IV J9181
oral 50 mg ORAL J8560
Euflexxa per dose OTH J7323
Everolimus 0.25 mg ORAL J7527
Everone 1 mg IM J3121
Evinacumab-dgnb 5 mg IV J1305
Evomela 50 mg J9245
Eylea 1 mg OTH J0178
F
Fabrazyme 1 mg IV J0180
Factor IX
anti-hemophilic factor, per IU IV J7193
purified, non-recombinant
anti-hemophilic factor, per IU IV J7195,
recombinant J7200-
J7202
complex per IU IV J7194
Factor VIIa (coagulation factor, 1 mcg IV J7189
recombinant)
Factor VIII (anti-hemophilic per IU IV J7208
factor)
human per IU IV J7190
porcine per IU IV J7191
recombinant per IU IV J7182,
J7185,
J7192,
J7188
Factor VIII (anti-hemophilic
factor, recombinant)
(Afstyla) per IU IV J7210
Esperoct per IU IV J7204
Jivi per IU IV J7208
(Kovaltry) per IU IV J7211
Novoeight per IU IV J7182
Obizur per IU IV J7188
Xyntha per IU IV J7185
Factor VIII, anti-hemophilic per IU IV J7204
factor (recombinant)(esperoct)
Factor VIII Fc fusion per IU IV J7205,
(recombinant) J7207,
 J7209
Factor X (human) per IU IV J7175
Factor XIII A-subunit per IU IV J7181
(recombinant)
Factors, other hemophilia clotting per IU IV J7196
Factrel per 100 mcg SC, IV J1620
Fam-trastuzumab deruxtecan- 1 mg IM J9358
nxki
Famotidine J3490
Faricimab-svoa 0.1 mg IM J2777 ◀
Faslodex 25 mg J9395
Feiba NF J7198
Feiba VH Immuno per IU IV J7196
Fentanyl citrate 0.1 mg IM, IV J3010
Feraheme 1 mg Q0138,
Q0139
Ferric carboxymaltose 1 mg IV J1439
Ferric pyrophosphate citrate 0.1 mg of iron IV J1444
powder
Ferric pyrophosphate citrate 0.1 mg of iron IV J1443
solution (triferic)
Ferric pyrophosphate citrate 0.1 mg of iron IV J1445
solution (triferic avnu)
Ferrlecit 12.5 mg J2916
Ferumoxytol 1 mg Q0138,
Q0139
Filgrastim-aafi 1 mcg IV Q5110
Filgrastim
(G-CSF) 1 mcg SC, IV J1442,
Q5101
(TBO) 1 mcg IV J1447
Firazyr 1 mg SC J1744
Firmagon 1 mg J9155
Flebogamma 500 mg IV J1572
1 cc J1460
Flexoject up to 60 mg IV, IM J2360
Flexon up to 60 mg IV, IM J2360
Flolan 0.5 mg IV J1325
Flo-Pred 5 mg J7510
Florbetaben f18, diagnostic per study dose IV Q9983
Floxuridine 500 mg IV J9200
Fluconazole 200 mg IV J1450
Fludara 1 mg ORAL J8562
50 mg IV J9185
Fludarabine phosphate 1 mg ORAL J8562
50 mg IV J9185
Flunisolide inhalation solution, per mg INH J7641
unit dose form
Fluocinolone OTH J7311,
J7313
Fluocinolone acetonide (Yutiq) 0.01 mg OTH J7314
Fluorouracil 500 mg IV J9190
Fluphenazine decanoate up to 25 mg J2680
Flutamide J8999
Flutemetamol f18, diagnostic per study dose IV Q9982
Folex 5 mg IA, IM, IT, J9250
IV
50 mg IA, IM, IT, J9260
IV

Folex PFS 5 mg IA, IM, IT, J9250

IV
 50 mg IA, IM, IT, J9260
IV
Follutein per 1,000 USP IM J0725
units
Folotyn 1 mg J9307
Fomepizole 15 mg J1451
Fomivirsen sodium 1.65 mg Intraocular J1452
Fondaparinux sodium 0.5 mg SC J1652
Formoterol 12 mcg INH J7640
Formoterol fumarate 20 mcg INH J7606
Fortaz per 500 mg IM, IV J0713
Fosaprepitant 1 mg IV J1453, ◀
J1456
Foscarnet sodium per 1,000 mg IV J1455
Foscavir per 1,000 mg IV J1455
Fosnetupitant 235 mg and IV J1454
palonosetron 0.25 mg
Fosphenytoin 50 mg IV Q2009
Fragmin per 2,500 IU J1645
Fremanezumab-vfrm 1 mg IV J3031
FUDR 500 mg IV J9200
Fulvestrant 25 mg IM J9393, ◀
J9394,
J9395
Fungizone intravenous 50 mg IV J0285
Furomide M.D. up to 20 mg IM, IV J1940
Furosemide up to 20 mg IM, IV J1940
G
Gablofen 10 mg J0475
50 mcg J0476
Gadavist 0.1 ml A9585
Gadoxetate disodium 1 ml IV A9581
Gallium nitrate 1 mg IV J1457
Galsulfase 1 mg IV J1458
Gamastan 1 cc IM J1460
over 10 cc IM J1560
Gamma globulin 1 cc IM J1460
over 10 cc IM J1560
Gammagard Liquid 500 mg IV J1569
Gammagard S/D J1566
GammaGraft per square Q4111
centimeter
Gammaplex 500 mg IV J1557
Gammar 1 cc IM J1460
over 10 cc IM J1560
Gammar-IV, see Immune globin
intravenous (human)
Gamulin RH
immune globulin, human 100 IU J2791
1 dose package, IM J2790
300 mcg
immune globulin, human, 100 IU IV J2792
solvent detergent
Gamunex 500 mg IV J1561
Ganciclovir, implant 4.5 mg OTH J7310
Ganciclovir sodium 500 mg IV J1570, ◀
J1574
Ganirelix J3490

Garamycin, gentamicin up to 80 mg IM, IV J1580

Gastrografin per ml Q9963
Gatifloxacin 10 mg IV J1590
Gazyva 10 mg J9301
Gefitinib 250 mg ORAL J8565
Gel-One per dose OTH J7326
Gemcitabine HCl 200 mg IV J9201
Gemcitabine HCl, not otherwise 200 mg IV J9201
specified
Gemcitabine HCI (Infugem) 100 mg IV J9198
Gemsar 200 mg IV J9201
Gemtuzumab ozogamicin 5 mg IV J9300
Gengraf 100 mg J7502
25 mg ORAL J7515
Genotropin 1 mg J2941
Gentamicin Sulfate up to 80 mg IM, IV J1580,
J7699
Gentran 500 ml IV J7100
Gentran 75 500 ml IV J7110
Geodon 10 mg J3486
Gesterol 50 per 50 mg J2675
Givosiran 0.5 mg IM J0223
Glassia 10 mg IV J0257
Glatiramer Acetate 20 mg SC J1595
Gleevec (Film-Coated) 400 mg J8999
GlucaGen per 1 mg J1610
Glucagon HCl per 1 mg SC, IM, IV J1610, ◀
J1611
Glukor per 1,000 USP IM J0725
units
Glycopyrrolate
concentrated form per 1 mg INH J7642
unit dose form per 1 mg INH J7643
Gold sodium thiomalate up to 50 mg IM J1600
Golimumab 1 mg IV J1602
Golodirsen 10 mg IM J1429
Gonadorelin HCl per 100 mcg SC, IV J1620
Gonal-F J3490
Gonic per 1,000 USP IM J0725
units
Goserelin acetate implant per 3.6 mg SC J9202
Graftjacket per square Q4107
centimeter
Graftjacket Xpress 1 cc Q4113
Granisetron HCl
extended release 0.1 mg IV J1627
injection 100 mcg IV J1626
oral 1 mg ORAL Q0166
Guselkumab 1 mg IV J1628
Gynogen L.A. A10 up to 10 mg IM J1380
Gynogen L.A. A20 up to 10 mg IM J1380
Gynogen L.A. A40 up to 10 mg IM J1380
H
Halaven 0.1 mg J9179
Haldol up to 5 mg IM, IV J1630
Haloperidol up to 5 mg IM, IV J1630
Haloperidol decanoate per 50 mg IM J1631
Haloperidol Lactate up to 5 mg J1630
Hectoral 1 mcg IV J1270
Helixate FS per IU J7192
Hemin 1 mg J1640
Hemofil M per IU IV J7190
Hemophilia clotting factors (e.g., per IU IV J7198
anti-inhibitors)
NOC per IU IV J7199
Hepagam B 0.5 ml IM J1571
0.5 ml IV J1573
Heparin sodium 1,000 units IV, SC J1643, ◀
J1644
Heparin sodium (heparin lock 10 units IV J1642
flush)
Heparin Sodium (Procine) per 1,000 units J1644
Hep-Lock 10 units IV J1642
Hep-Lock U/P 10 units IV J1642
Herceptin 10 mg IV J9355
Hexabrix 320 per ml Q9967
Hexadrol Phosphate 1 mg IM, IV, J1100
OTH
Hexaminolevulinate 100 mg IV A9589
hydrochloride
Histaject per 10 mg IM, SC, IV J0945
Histerone 50 up to 50 mg IM J3140
Histerone 100 up to 50 mg IM J3140
Histrelin
acetate 10 mcg J1675
implant 50 mg OTH J9225,
J9226
Hizentra, see Immune globulin
Humalog per 5 units J1815
 per 50 units J1817
Human fibrinogen concentrate 100 mg IV J7178
Human fibrinogen concentrate 1 mg IV J7177
(fibryga)
Humate-P per IU J7187
Humatrope 1 mg J2941
Humira 20 mg J0135
Humulin per 5 units J1815
per 50 units J1817
Hyalgan, Spurtaz or VISCO-3 per dose IA J7321
Hyaluronan or derivative per dose IV J7327
Durolane 1 mg IA J7318
Gel-Syn 0.1 mg IA J7328
Gelsyn-3 0.1 mg IV J7328
Gen Visc 850 1 mg IA J7320
Hyalgan or supartz per dose IA J7321
Hymovis 1 mg IA J7322
Synojoynt 1 mg VAR J7331
Triluron 1 mg IV J7332
Trivisc 1 mg IV J7329
Hyaluronic Acid J3490
Hyaluronidase up to 150 units SC, IV J3470
Hyaluronidase
ovine up to 999 units VAR J3471
ovine per 1000 units VAR J3472
recombinant 1 usp SC J3473
Hyate:C per IU IV J7191
Hybolin Decanoate up to 50 mg IM J2320
Hycamtin 0.25 mg ORAL J8705
4 mg IV J9351
Hydralazine HCl up to 20 mg IV, IM J0360
Hydrate up to 50 mg IM, IV J1240
Hydrea J8999
Hydrocortisone acetate up to 25 mg IV, IM, SC J1700
Hydrocortisone sodium up to 50 mg IV, IM, SC J1710
phosphate
Hydrocortisone succinate sodium up to 100 mg IV, IM, SC J1720
Hydrocortone Acetate up to 25 mg IV, IM, SC J1700
Hydrocortone Phosphate up to 50 mg IM, IV, SC J1710
Hydromorphone HCl up to 4 mg SC, IM, IV J1170
Hydroxyprogesterone Caproate 1 mg IM J1725
(Makena) 10 mg IV J1726
NOS 10 mg IV J1729
Hydroxyurea J8999
Hydroxyzine HCl up to 25 mg IM J3410
Hydroxyzine Pamoate 25 mg ORAL Q0177
Hylan G-F 20 OTH J7322
Hylenex 1 USP unit J3473
Hyoscyamine sulfate up to 0.25 mg SC, IM, IV J1980
Hyperrho S/D 300 mcg J2790
100 IU J2792
Hyperstat IV up to 300 mg IV J1730
Hyper-Tet up to 250 units IM J1670
HypRho-D 300 mcg IM J2790
J2791

50 mcg J2788
Hyrexin-50 up to 50 mg IV, IM J1200
Hyzine-50 up to 25 mg IM J3410
I
Ibalizumab-uiyk 10 mg IV J1746
Ibandronate sodium 1 mg IV J1740
Ibuprofen 100 mg IV J1741
Ibutilide fumarate 1 mg IV J1742
Icatibant 1 mg SC J1744
Idamycin 5 mg IV J9211
Idarubicin HCl 5 mg IV J9211
Idursulfase 1 mg IV J1743
Ifex 1g IV J9208
Ifosfamide 1g IV J9208
Ilaris 1 mg J0638
Iloprost 20 mcg INH Q4074
Ilotycin, see Erythromycin
lactobionate
Iluvien 0.01 mg J7313
Imferon 50 mg J1750
Imiglucerase 10 units IV J1786
Imipenem 4 mg, cilistatin 4 mg, J0742
relebactam 2 mg
Imitrex 6 mg SC J3030
Imlygic per 1 million J9325,
plaque forming J9999
units
Immune globulin
Asceniv 500 mg IV J1554
Bivigam 500 mg IV J1556
 Cuvitru 100 mg IV J1555
Flebogamma 500 mg IV J1572
Gammagard Liquid 500 mg IV J1569
Gammaplex 500 mg IV J1557
Gamunex 500 mg IV J1561
HepaGam B 0.5 ml IM J1571
0.5 ml IV J1573
Hizentra 100 mg SC J1559
Hyaluronidase, (HYQVIA) 100 mg IV J1575
NOS 500 mg IV J1566,
J1599
Octagam 500 mg IV J1568
Privigen 500 mg IV J1459
Rhophylac 100 IU IM J2791
Subcutaneous 100 mg SC J1562
Xembify 100 mg IM J1558
Immunosuppressive drug, not J7599
otherwise classified
Imuran 50 mg ORAL J7500
100 mg IV J7501
Inapsine up to 5 mg IM, IV J1790
Inclisiran 1 mg IM J1306 ◀
Incobotulinumtoxin type A 1 unit IM J0588
Increlex 1 mg J2170
Inderal up to 1 mg IV J1800
Inebilizumab-cdon 1 mg IV J1823
Infed 50 mg J1750
Infergen 1 mcg SC J9212
Inflectra Q5102
Infliximab
dyyb 10 mg IM, IV Q5103
abda 10 mg IM, IV Q5104
axxq, biosimilar, (AVSOLA) 10 mg IM, IV Q5121
qbtx 10 mg IM, IV Q5109
Infumorph 10 mg J2274
Injectafer 1 mg J1439
Injection factor XL, 1 IU IV J7203
glycopegylated
Injection sulfur hexafluoride lipid per ml IV Q9950
microspheres
Innohep 1,000 iu SC J1655
Innovar up to 2 ml ampule IM, IV J1810
Inotuzumab orogamicin 0.1 mg IV J9229
Insulin 5 units SC J1815
Insulin-Humalog per 50 units J1817
Insulin lispro 50 units SC J1817
Intal, unit dose form per 10 mg INH J7631,
J7632
Integra
Bilayer Matrix Wound per square Q4104
Dressing (BMWD) centimeter
Dermal Regeneration Template per square Q4105
(DRT) centimeter
Flowable Wound Matrix 1 cc Q4114
Matrix per square Q4108
centimeter
Integrilin IV injection 5 mg IM, IV J1327
Interferon alfa-2a, recombinant 3 million units SC, IM J9213
Interferon alfa-2b, recombinant 1 million units SC, IM J9214
Interferon alfa-n3 (human 250,000 IU IM J9215
leukocyte derived)
Interferon alphacon-1, 1 mcg SC J9212
recombinant
Interferon beta-1a 30 mcg IM J1826
1 mcg IM Q3027
1 mcg SC Q3028
Interferon beta-1b 0.25 mg SC J1830
Interferon gamma-1b 3 million units SC J9216
Intrauterine copper contraceptive OTH J7300
Intron-A 1 million units J9214
Invanz 500 mg J1335
Invega Sustenna 1 mg J2426
Ipilimumab 1 mg IV J9228
Ipratropium bromide, unit dose per mg INH J3535,
form J7620,
J7644,
J7645
Irinotecan 20 mg IV J9206,
J9205
Iron dextran 50 mg IV, IM J1750
Iron sucrose 1 mg IV J1756
Irrigation solution for Tx of per 50 ml OTH Q2004
bladder calculi
Isatuximab-irfc 10 mg IV J9227
Isavuconazonium 1 mg IV J1833
Isocaine HCl per 10 ml VAR J0670

Isoetharine HCl
concentrated form per mg INH J7647,
J7648
 unit dose form per mg INH J7649,
J7650
Isoproterenol HCl
concentrated form per mg INH J7657,
J7658
unit dose form per mg INH J7659,
J7660
Isovue per ml Q9966,
Q9967
Isuprel
concentrated form per mg INH J7657,
J7658
unit dose form per mg INH J7659,
J7660
Itraconazole 50 mg IV J1835
Ixabepilone 1 mg IV J9207
Ixempra 1 mg J9207
J
Jemperli 10 mg IV J9272
Jenamicin up to 80 mg IM, IV J1580
Jetrea 0.125 mg J7316
Jevtana 1 mg J9043
K
Kabikinase per 250,000 IU IV J2995
Kadcyla 1 mg J9354
Kalbitor 1 mg J1290
Kaleinate per 10 ml IV J0610
Kanamycin sulfate up to 75 mg IM, IV J1850

up to 500 mg IM, IV J1840

Kantrex up to 75 mg IM, IV J1850
 up to 500 mg IM, IV J1840
Keflin up to 1 g IM, IV J1890
Kefurox per 750 mg J0697
Kefzol 500 mg IV, IM J0690
Kenaject-40 1 mg J3300
per 10 mg IM J3301
Kenalog-10 1 mg J3300
per 10 mg IM J3301
Kenalog-40 1 mg J3300
per 10 mg IM J3301
Kepivance 50 mcg J2425
Keppra 10 mg J1953
Keroxx 1 cc IV Q4202
Kestrone 5 per 1 mg IM J1435
Ketorolac tromethamine per 15 mg IM, IV J1885
Key-Pred 25 up to 1 ml IM J2650
Key-Pred 50 up to 1 ml IM J2650
Key-Pred-SP, see Prednisolone
sodium phosphate
Keytruda 1 mg J9271
K-Flex up to 60 mg IV, IM J2360
Khapzory 0.5 mg IV J0642
Kinevac 5 mcg IV J2805
Kitabis PAK per 300 mg J7682
Klebcil up to 75 mg IM, IV J1850
up to 500 mg IM, IV J1840

Koate-HP (anti-hemophilic
factor)
 human per IU IV J7190
porcine per IU IV J7191
recombinant per IU IV J7192
Kogenate
human per IU IV J7190
porcine per IU IV J7191
recombinant per IU IV J7192
Konakion per 1 mg IM, SC, IV J3430
Konyne-80 per IU IV J7194
Krystexxa 1 mg J2507
Kyleena 19.5 mg OTH J7296
Kyprolis 1 mg J9047
Kytril 1 mg ORAL Q0166
1 mg IV S0091
100 mcg IV J1626
L
L.A.E. 20 up to 10 mg IM J1380
Laetrile, Amygdalin, vitamin B- J3570
17
Lanadelumab-flyo 1 mg IV J0593
Lanoxin up to 0.5 mg IM, IV J1160
Lanreotide 1 mg SC J1930, ◀
J1932
Lantus per 5 units J1815
Largon, see Propiomazine HCl
Laronidase 0.1 mg IV J1931
Lasix up to 20 mg IM, IV J1940

L-Caine 10 mg IV J2001
Lefamulin 1 mg J0691
Lemtrada 1 mg J0202
Lepirudin 50 mg J1945
Leucovorin calcium per 50 mg IM, IV J0640
Leukeran J8999
Leukine 50 mcg IV J2820
Leuprolide acetate per 1 mg IM J9218
Leuprolide acetate (for depot per 3.75 mg IM J1950
suspension)
7.5 mg IM J9217
Leuprolide acetate (for depot 0.25 mg IV J1951
suspension) (fensolvi)
Leuprolide acetate implant 65 mg OTH J9219
Leustatin per mg IV J9065
Levalbuterol HCl
concentrated form 0.5 mg INH J7607,
J7612
unit dose form 0.5 mg INH J7614,
J7615
Levaquin I.U. 250 mg IV J1956
Levetiracetam 10 mg IV J1953
Levocarnitine per 1 gm IV J1955
Levo-Dromoran up to 2 mg SC, IV J1960
Levofloxacin 250 mg IV J1956
Levoleucovorin NOS 0.5 mg IV J0641
Levonorgestrel implant OTH J7306
Levonorgestrel-releasing 52 mg OTH J7297,
intrauterine contraceptive system J7298
Kyleena 19.5 mg OTH J7296
Levorphanol tartrate up to 2 mg SC, IV J1960
Levsin up to 0.25 mg SC, IM, IV J1980
Levulan Kerastick unit dose (354 OTH J7308
mg)
Lexiscan 0.1 mg J2785
Librium up to 100 mg IM, IV J1990
Lidocaine HCl 10 mg IV J2001
Lidoject-1 10 mg IV J2001
Lidoject-2 10 mg IV J2001
Liletta 52 mg OTH J7297
Lincocin up to 300 mg IV J2010
Lincomycin HCl up to 300 mg IV J2010
Linezolid 200 mg IV J2020, ◀
J2021
Lioresal 10 mg IT J0475
J0476
Liposomal
Cytarabine 2.27 mg IV J9153
Daunorubicin 1 mg IV J9153
Liquaemin Sodium 1,000 units IV, SC J1644
LMD (10%) 500 ml IV J7100
Locort 1.5 mg J8540
Lorazepam 2 mg IM, IV J2060
Lovenox 10 mg SC J1650
Loxapine 1 mg OTH J2062
Lucentis 0.1 mg J2778
Lufyllin up to 500 mg IM J1180
Lumasiran 0.5 mg IV J0224
Lumason per ml Q9950
Luminal Sodium up to 120 mg IM, IV J2560
Lumizyme 10 mg J0221
Lupon Depot 7.5 mg J9217
3.75 mg J1950
Lupron per 1 mg IM J9218
per 3.75 mg IM J1950
7.5 mg IM J9217
Lurbinectedin 0.1 mg IV J9223
Luspatercept-aamt 0.25 mg IM J0896
Lyophilized, see
Cyclophosphamide, lyophilized
M
Macugen 0.3 mg J2503
Magnesium sulfate 500 mg J3475
Magnevist per ml A9579
Makena 1 mg J1725
Mannitol 25% in 50 ml IV J2150
5 mg INH J7665
Marcaine J3490
Margetuximab-cmkb 5 mg IV J9353
Marinol 2.5 mg ORAL Q0167
Marmine up to 50 mg IM, IV J1240
Matulane 50 mg J8999
Maxipime 500 mg IV J0692
MD-76R per ml Q9963
MD Gastroview per ml Q9963
Mecasermin 1 mg SC J2170
Mechlorethamine HCl (nitrogen 10 mg IV J9230
mustard), HN2

Medralone 40 20 mg IM J1020
40 mg IM J1030
 80 mg IM J1040
Medralone 80 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
Medrol per 4 mg ORAL J7509
Medroxyprogesterone acetate 1 mg IM J1050
Mefoxin 1g IV, IM J0694
Megestrol Acetate J8999
Meloxicam 1 mg IV J1738
Melphalan (evomela) 1 mg IV J9246
Melphanlan flufenamide 1 mg IV J9247
Melphalan HCl 50 mg IV J9245
Melphalan, oral 2 mg ORAL J8600
Menoject LA 1 mg J1071
Mepergan injection up to 50 mg IM, IV J2180
Meperidine and promethazine up to 50 mg IM, IV J2180
HCl
Meperidine HCl per 100 mg IM, IV, SC J2175
Mepivacaine HCl per 10 ml VAR J0670
Mepolizumab 1 mg IV J2182
Mercaptopurine J8999
Meropenem 100 mg IV J2184, ◀
J2185
Merrem 100 mg J2185
Mesna 200 mg IV J9209
Mesnex 200 mg IV J9209
Metaprel
concentrated form per 10 mg INH J7667,
J7668
 unit dose form per 10 mg INH J7669,
J7670
Metaproterenol sulfate
concentrated form per 10 mg INH J7667,
J7668
unit dose form per 10 mg INH J7669,
J7670
Metaraminol bitartrate per 10 mg IV, IM, SC J0380
Metastron per millicurie A9600
Methacholine chloride 1 mg INH J7674
Methadone HCl up to 10 mg IM, SC J1230
Methergine up to 0.2 mg J2210
Methocarbamol up to 10 ml IV, IM J2800
Methotrexate LPF 5 mg IV, IM, IT, J9250
IA
50 mg IV, IM, IT, J9260
IA
Methotrexate, oral 2.5 mg ORAL J8610
Methotrexate sodium 5 mg IV, IM, IT, J9250
IA
50 mg IV, IM, IT, J9260
IA
Methyldopate HCl up to 250 mg IV J0210
Methylergonovine maleate up to 0.2 mg J2210
Methylnaltrexone 0.1 mg SC J2212
Methylprednisolone acetate 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
Methylprednisolone, oral per 4 mg ORAL J7509
Methylprednisolone sodium up to 40 mg IM, IV J2920
succinate
 up to 125 mg IM, IV J2930
Metoclopramide HCl up to 10 mg IV J2765
Metrodin 75 IU J3355
Metronidazole J3490
Metvixia 1g OTH J7309
Miacalcin up to 400 units SC, IM J0630
Micafungin sodium 1 mg J2247, ◀
J2248
MicRhoGAM 50 mcg J2788
Midazolam HCl per 1 mg IM, IV J2250, ◀
J2251
Milrinone lactate 5 mg IV J2260
Minocine 1 mg J2265
Minocycline Hydrochloride 1 mg IV J2265
Mircera 1 mcg J0887,
J0888
Mirena 52 mg OTH J7297,
J7298
Mithracin 2,500 mcg IV J9270
Mitomycin 0.2 mg Ophthalmic J7315
5 mg IV J9280
Mitosol 0.2 mg Ophthalmic J7315
5 mg IV J9280
Mitoxantrone HCl per 5 mg IV J9293
Mogamulizumab-kpkc 1 mg IV J9204
Mometasone furoate sinus 10 mcg OTH J7402
implant, (sinuva)

Monocid, see Cefonicic sodium

Monoclate-P
 human per IU IV J7190
porcine per IU IV J7191
Monoclonal antibodies, parenteral 5 mg IV J7505
Mononine per IU IV J7193
Monovisc J7327
Morphine sulfate up to 10 mg IM, IV, SC J2270, ◀
J2272
preservative-free 10 mg SC, IM, IV J2274
Moxetumomab Pasudotox-tdfk 0.01 mg IV J9313
Moxifloxacin 100 mg IV J2280, ◀
J2281
Mozobil 1 mg J2562
M-Prednisol-40 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
M-Prednisol-80 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
Mucomyst
unit dose form per gram INH J7604,
J7608
Mucosol
injection 100 mg IV J0132
unit dose per gram INH J7604,
J7608
MultiHance per ml A9577

MultiHance Multipack per ml A9578

Muromonab-CD3 5 mg IV J7505
Muse OTH J0275
 1.25 mcg OTH J0270
Mustargen 10 mg IV J9230
Mutamycin
0.2 mg Ophthalmic J7315
5 mg IV J9280
Mycamine 1 mg J2248
Mycophenolate Mofetil 250 mg ORAL J7517
Mycophenolic acid 180 mg ORAL J7518
Myfortic 180 mg J7518
Myleran 1 mg J0594
2 mg ORAL J8510
Mylotarg 5 mg IV J9300
Myobloc per 100 units IM J0587
Myochrysine up to 50 mg IM J1600
Myolin up to 60 mg IV, IM J2360
N
Nabilone 1 mg ORAL J8650
Nafcillin J3490
Naglazyme 1 mg J1458
Nalbuphine HCl per 10 mg IM, IV, SC J2300
Naloxone HCl per 1 mg IM, IV, SC J2310, ◀
J2311,
J3490
Naltrexone J3490
Naltrexone, depot form 1 mg IM J2315
Nandrobolic L.A. up to 50 mg IM J2320

Nandrolone decanoate up to 50 mg IM J2320

Narcan 1 mg IM, IV, SC J2310
Naropin 1 mg J2795
Nasahist B per 10 mg IM, SC, IV J0945
Nasal vaccine inhalation INH J3530
Natalizumab 1 mg IV J2323
Natrecor 0.1 mg J2325
Navane, see Thiothixene
Navelbine per 10 mg IV J9390
Naxitamab-gqgk 1 mg IV J9348
ND Stat per 10 mg IM, SC, IV J0945
Nebcin up to 80 mg IM, IV J3260
NebuPent per 300 mg INH J2545,
J7676
Necitumumab 1 mg IV J9295
Nelarabine 50 mg IV J9261
Nembutal Sodium Solution per 50 mg IM, IV, J2515
OTH
Neocyten up to 60 mg IV, IM J2360
Neo-Durabolic up to 50 mg IM J2320
Neoquess up to 20 mg IM J0500
Neoral 100 mg J7502
25 mg J7515
Neosar 100 mg IV J9070
Neostigmine methylsulfate up to 0.5 mg IM, IV, SC J2710
Neo-Synephrine up to 1 ml SC, IM, IV J2370
Nervocaine 1% 10 mg IV J2001
Nervocaine 2% 10 mg IV J2001
Nesacaine per 30 ml VAR J2400 ✖
Nesacaine-MPF per 30 ml VAR J2400 ✖
Nesiritide 0.1 mg IV J2325
Netupitant 300 mg and ORAL J8655
palonosetron 0.5 mg
Neumega 5 mg SC J2355
Neupogen
(G-CSF) 1 mcg SC, IV J1442
Neutrexin per 25 mg IV J3305
Nipent per 10 mg IV J9268
Nivol relatlimab 3mg/1mg IM J9298 ◀
Nivolumab 1 mg IV J9299
Nolvadex J8999
Nordryl up to 50 mg IV, IM J1200
50 mg ORAL Q0163
Norflex up to 60 mg IV, IM J2360
Norzine up to 10 mg IM J3280
Not otherwise classified drugs J3490
other than inhalation solution J7799
administered through DME
inhalation solution J7699
administered through DME
anti-neoplastic J9999
chemotherapeutic ORAL J8999
immunosuppressive J7599
nonchemotherapeutic ORAL J8499
Novantrone per 5 mg IV J9293
Novarel per 1,000 USP J0725
Units

Novolin per 5 units J1815

per 50 units J1817
Novolog per 5 units J1815
 per 50 units J1817
Novo Seven 1 mcg IV J7189
Novoeight J7182
NPH 5 units SC J1815
Nplate 100 units J0587
10 mcg J2796
Nubain per 10 mg IM, IV, SC J2300
Nulecit 12.5 mg J2916
Nulicaine 10 mg IV J2001
Nulojix 1 mg IV J0485
Numorphan up to 1 mg IV, SC, IM J2410
Numorphan H.P. up to 1 mg IV, SC, IM J2410
Nusinersen 0.1 mg IV J2326
Nutropin 1 mg J2941
O
Oasis Burn Matrix per square Q4103
centimeter
Oasis Wound Matrix per square Q4102
centimeter
Obinutuzumab 10 mg J9301
Ocriplasmin 0.125 mg IV J7316
Ocrelizumab 1 mg IV J2350
Octagam 500 mg IV J1568
Octreotide Acetate, injection 1 mg IM J2353
25 mcg IV, SQ J2354
Oculinum per unit IM J0585
Ofatumumab 10 mg IV J9302
Ofev J8499
Ofirmev 10 mg IV J0131
O-Flex up to 60 mg IV, IM J2360
Oforta 10 mg J8562
Olanzapine 1 mg IM J2358
Olaratumab 10 mg IV J9285
Omadacycline 1 mg IV J0121
Omacetaxine Mepesuccinate 0.01 mg IV J9262
Omalizumab 5 mg SC J2357
Omnipaque per ml Q9965,
Q9966,
Q9967
Omnipen-N up to 500 mg IM, J0290
IV
per 1.5 gm IM, J0295
IV
Omniscan per ml A9579
Omnitrope 1 mg J2941
Omontys 0.1 mg IV, SC J0890
OnabotulinumtoxinA 1 unit IM J0585
Onasemnogene abeparvovec-xioi, up to 5x10 15 IM J3399
per treatment, vector genomes
Oncaspar per single dose IM, J9266
vial IV
Oncovin 1 mg IV J9370
Ondansetron HCI 1 mg IV J2405
1 mg ORAL Q0162
Onivyde 1 mg J9205
Opana up to 1 mg J2410
Opdivo 1 mg J9299
Oprelvekin 5 mg SC J2355
Optimark per ml A9579
Optiray per ml Q9966,
Q9967
Optison per ml Q9956
Oraminic II per 10 mg IM, J0945
SC,
IV
Orapred per 5 mg ORAL J7510
Orbactiv 10 mg J2407
Orencia 10 mg J0129
Oritavancin (kimyrsa) 10 mg IV J2406
Oritavancin (orbactiv) 10 mg IV J2407
Ormazine up to 50 mg IM, J3230
IV
Orphenadrine citrate up to 60 mg IV, IM J2360
Orphenate up to 60 mg IV, IM J2360
Orthovisc OTH J7324
Or-Tyl up to 20 mg IM J0500
Osmitrol J7799
Ovidrel J3490
Oxacillin sodium up to 250 mg IM, J2700
IV
Oxaliplatin 0.5 mg IV J9263
Oxilan per ml Q9967
Oxymorphone HCl up to 1 mg IV, J2410
SC,
IM
Oxytetracycline HCl up to 50 mg IM J2460
Oxytocin up to 10 units IV, IM J2590
Ozurdex 0.1 mg J7312
P
Paclitaxel 1 mg IV J9267
Paclitaxel protein-bound particles 1 mg IV J9264
Palifermin 50 mcg IV J2425
Paliperidone palmitate 1 mg IM J2426
Palonosetron HCl 25 mcg IV J2469
Netupitant 300 mg and ORAL J8655
palonosetron 0.5 mg
Pamidronate disodium per 30 mg IV J2430
Panhematin 1 mg J1640
Panitumumab 10 mg IV J9303
Papaverine HCl up to 60 mg IV, IM J2440
Paragard T 380 A OTH J7300
Paraplatin 50 mg IV J9045
Paricalcitol, injection 1 mcg IV, IM J2501
Pasireotide, long acting 1 mg IV J2502
Pathogen(s) test for platelets OTH P9100
Patisiran 0.1 mg IV J0222
Peforomist 20 mcg J7606
Pegademase bovine 25 IU J2504
Pegaptinib 0.3 mg OTH J2503
Pegaspargase per single dose IM, J9266
vial IV
Pegasys J3490
Pegfilgrastim-bmez, biosimilar, 0.5 mg IM Q5120
(ziextenzo)
Pegfilgrastim-jmdb 0.5 mg SC Q5108
Peginesatide 0.1 mg IV, SC J0890
Peg-Intron J3490
Pegloticase 1 mg IV J2507
Pembrolizumab 1 mg IV J9271
Pemetrexed 10 mg IV J9305
Pemetrexed (Pemfexy) 10 mg IV J9304
Penicillin G Benzathine 100,000 units IM J0561
Penicillin G Benzathine and 100,000 units IM J0558
Penicillin G Procaine
Penicillin G potassium up to 600,000 IM, J2540
units IV
Penicillin G procaine, aqueous up to 600,000 IM, J2510
units IV
Penicillin G Sodium J3490
Pentam per 300 mg J7676
Pentamidine isethionate per 300 mg INH, J2545, J7676
IM
Pentastarch, 10% 100 ml J2513
Pentazocine HCl 30 mg IM, J3070
 SC,
IV

Pentobarbital sodium per 50 mg IM, J2515

IV,
OTH
Pentostatin per 10 mg IV J9268
Peramivir 1 mg IV J2547
Perjeta 1 mg J9306
Permapen up to 600,000 IM J0561
Perphenazine
injection up to 5 mg IM, J3310
IV
tablets 4 mg ORAL Q0175
Persantine IV per 10 mg IV J1245
Pertuzumab 1 mg IV J9306
Pet Imaging
Fluciclovine F-18, diagnostic 1 millcurie IV A9588
Gallium Ga-68, dotatate, 0.1 millicurie IV A9587
diagnostic
Gallium ga-68, psma-11, (ucla) 1 millicurie IV A9594
Gallium ga-68, psma-11, (ucsf) 1 millicurie IV A9593
Pfizerpen up to 600,000 IM, J2540
units IV
Pfizerpen A.S. up to 600,000 IM, J2510
units IV
Phenadoz J8498
Phenazine 25 up to 50 mg IM, J2550
IV
12.5 mg ORAL Q0169
Phenazine 50 up to 50 mg IM, J2550
IV
 12.5 mg ORAL Q0169

Phenergan 12.5 mg ORAL Q0169

up to 50 mg IM, J2550
IV
J8498
Phenobarbital sodium up to 120 mg IM, J2560
IV
Phentolamine mesylate up to 5 mg IM, J2760
IV
Phenylephrine HCl up to 1 ml SC, J2370, J7799
IM,
IV
Phenylephrine 10.16 mg/Ketorolac 1 ml VAR J1097
2.88
Phenytoin sodium per 50 mg IM, J1165
IV
Photofrin 75 mg IV J9600
Phytonadione (Vitamin K) per 1 mg IM, J3430
SC,
IV
Piperacillin/Tazobactam Sodium, 1.125 g IV J2543
injection
Pitocin up to 10 units IV, IM J2590
Plantinol AQ 10 mg IV J9060
Plasma
cryoprecipitate reduced each unit IV P9044
pooled multiple donor, frozen each unit IV P9023, P9070
(single donor), pathogen reduced, each unit IV P9071
frozen
Plasminogen TVMH 1 mg J2998 ◀
Plas+SD each unit IV P9023
Platelets, pheresis, pathogen reduced each unit IV P9073
 Pathogen(s) test for platelets OTH P9100
Platinol 10 mg IV, IM J9060
Plazomicin 5 mg IV J0291
Plerixafor 1 mg SC J2562
Plicamycin 2,500 mcg IV J9270
Polatuzumab vedotin 1 mg IV J9309
Polocaine per 10 ml VAR J0670
Polycillin-N up to 500 mg IM, J0290
IV
per 1.5 gm IM, J0295
IV
Polygam 500 mg J1566
Porfimer Sodium 75 mg IV J9600
Portrazza 1 mg J9295
Positron emission tomography
radiopharmaceutical, diagnostic
for non-tumor identification, NOC IV A9598
for tumor identification, NOC IV A9597
Potassium chloride per 2 mEq IV J3480
Potassium Chloride up to 1,000 cc J7120
Pralatrexate 1 mg IV J9307
Pralidoxime chloride up to 1 g IV, J2730
IM,
SC
Predalone-50 up to 1 ml IM J2650
Predcor-25 up to 1 ml IM J2650
Predcor-50 up to 1 ml IM J2650
Predicort-50 up to 1 ml IM J2650
Prednisolone acetate up to 1 ml IM J2650
Prednisolone, oral 5 mg ORAL J7510
Prednisone, immediate release or 1 mg ORAL J7512
delayed release
Predoject-50 up to 1 ml IM J2650
Pregnyl per 1,000 USP IM J0725
units
Premarin Intravenous per 25 mg IV, IM J1410
Prescription, chemotherapeutic, not ORAL J8999
otherwise specified
Prescription, nonchemotherapeutic, ORAL J8499
not otherwise specified
Prialt 1 mcg J2278
Primacor 5 mg IV J2260
Primatrix per square Q4110
centimeter
Primaxin per 250 mg IV, IM J0743
Priscoline HCl up to 25 mg IV J2670
Privigen 500 mg IV J1459
Probuphine System Kit J0570
Procainamide HCl up to 1 g IM, J2690
IV
Prochlorperazine up to 10 mg IM, J0780
IV
J8498
Prochlorperazine maleate 5 mg ORAL Q0164
5 mg S0183
Procrit J0885
Q4081
Pro-Depo, see Hydroxyprogesterone
Caproate

Profasi HP per 1,000 USP IM J0725

units
Profilnine Heat-Treated
non-recombinant per IU IV J7193
recombinant per IU IU J7195,
J7200-J7202
complex per IU IV J7194
Profonol 10 mg/ml J3490
Progestaject per 50 mg J2675
Progesterone per 50 mg IM J2675
Prograf
oral 1 mg ORAL J7507
parenteral 5 mg J7525
Prohance Multipack per ml A9576
Prokine 50 mcg IV J2820
Prolastin 10 mg IV J0256
Proleukin per single use vial IM, J9015
IV
Prolia 1 mg J0897
Prolixin Decanoate up to 25 mg IM, J2680
SC
Promazine HCl up to 25 mg IM J2950
Promethazine J8498
Promethazine HCl
injection up to 50 mg IM, J2550
IV
oral 12.5 mg ORAL Q0169
Promethegan J8498
Pronestyl up to 1 g IM, J2690
IV

Proplex SX-T
 non-recombinant per IU IV J7193
recombinant per IU J7195,
J7200-J7202
complex per IU IV J7194
Proplex T
non-recombinant per IU IV J7193
recombinant per IU J7195,
J7200-J7202
complex per IU IV J7194
Propofol 10 mg IV J2704
Propranolol HCl up to 1 mg IV J1800
Prorex-25
up to 50 mg IM, J2550
IV
12.5 mg ORAL Q0169
Prorex-50 up to 50 mg IM, J2550
IV
12.5 mg ORAL Q0169
Prostaglandin E1 per 1.25 mcg J0270
Prostaphlin up to 1 g IM, J2690
IV
Prostigmin up to 0.5 mg IM, J2710
IV, SC
Prostin VR Pediatric 0.5 mg J0270
Protamine sulfate per 10 mg IV J2720
Protein C Concentrate 10 IU IV J2724
Prothazine up to 50 mg IM, J2550
IV

12.5 mg ORAL Q0169

Prothrombin complex concentrate per i.u. of factor OTH J7168
(human), kcentra ix activity
Protirelin per 250 mcg IV J2725
Protonix J3490
Protopam Chloride up to 1 g IV, J2730
IM,
SC
Provenge Q2043
Proventil
concentrated form 1 mg INH J7610, J7611
unit dose form 1 mg INH J7609, J7613
Provocholine per 1 mg J7674
Prozine-50 up to 25 mg IM J2950
Pulmicort Respules
concentrated form 0.25 mg INH J7633, J7634
unit dose 0.5 mg INH J7626, J7627
Pulmozyme per mg J7639
Pyridoxine HCl 100 mg J3415
Q
Quelicin up to 20 mg IV, IM J0330
Quinupristin/dalfopristin 500 mg (150/350) IV J2770
Qutenza per square cm J7336
R
Ramucirumab 5 mg IV J9308
Ranibizumab 0.1 mg OTH J2778
Ranitidine HCl, injection 25 mg IV, IM J2780
Rapamune 1 mg ORAL J7520
Rasburicase 0.5 mg IV J2783
Ravulizumab-cwvz 10 mg IV J1303
Rebif 11 mcg Q3026
Reclast 1 mg J3489
Recombinate
human per IU IV J7190
porcine per IU IV J7191
recombinant per IU IV J7192
Recombivax J3490
Redisol up to 1,000 mcg IM, J3420
SC
Regadenoson 0.1 mg IV J2785
Regitine up to 5 mg IM, J2760
IV
Reglan up to 10 mg IV J2765
Regular 5 units SC J1815
Relefact TRH per 250 mcg IV J2725
Relistor 0.1 mg SC J2212
Remicade 10 mg IM, J1745
IV
Remodulin 1 mg J3285
Renflexis Q5102
ReoPro 10 mg IV J0130
Rep-Pred 40 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
Rep-Pred 80 20 mg IM J1020

40 mg IM J1030
80 mg IM J1040
Resectisol J7799
Reslizumab 1 mg IV J2786
Retavase 18.1 mg IV J2993
Reteplase 18.8 mg IV J2993
Retisert J7311
Retrovir 10 mg IV J3485
Revefenacin inhalation solution — INH J7677
Rheomacrodex 500 ml IV J7100
Rhesonativ 300 mcg IM J2790
50 mg J2788
Rheumatrex Dose Pack 2.5 mg ORAL J8610
Rho(D)
immune globulin IM, J2791
IV
immune globulin, human 1 dose IM J2790
package/300 mcg
50 mg IM J2788
immune globulin, human, solvent 100 IV, IU J2792
detergent
RhoGAM 300 mcg IM J2790
50 mg J2788
Rhophylac 100 IU IM, J2791
IV
Riastap 100 mg J7178
Rifadin J3490
Rifampin J3490
Rilonacept 1 mg SC J2793

RimabotulinumtoxinB 100 units IM J0587

Rimso-50 50 ml J1212
Ringers lactate infusion up to 1,000 cc IV J7120, J7121
Risankizumab 1 mg IV J2327 ◀
Risperdal Consta 0.5 mg J2794
Risperidone 0.5 mg IM J2794
Risperidone (perseris) 0.5 mg IV J2798
Rituxan 100 mg IV J9312
Rituximab 100 mg IV J9312
Rituximab-abbs 10 mg IV Q5115
Rituximab-arrx, biosimilar, (riabni) 10 mg IV Q5123
Rituximab-pvvr, biosimilar, 10 mg IV Q5119
(Ruxience)
Rixubis J7200
Robaxin up to 10 ml IV, IM J2800
Rocephin per 250 mg IV, IM J0696
Roferon-A 3 million units SC, J9213
IM
Rolapitant 0.5 mg IV J2797
Rolapitant, oral, 1 mg 1 mg ORAL J8670
Romidepsin lyophilized 1 mg IV J9319
Romidepsin, non-lyophilized 0.1 mg IV J9318
Romiplostim 10 mcg SC J2796
Romosozumab-aqqg 1 mg IV J3111
Ropivacaine Hydrochloride 1 mg OTH J2795
Rubex 10 mg IV J9000
Rubramin PC up to 1,000 mcg IM, J3420
SC

S
Saizen 1 mg J2941
Saline solution 10 ml A4216
5% dextrose 500 ml IV J7042
infusion 250 cc IV J7050
1,000 cc IV J7030
sterile 500 ml = 1 unit IV, J7040
 OTH
Sandimmune 25 mg ORAL J7515
100 mg ORAL J7502
250 mg OTH J7516
Sandoglobulin, see Immune globulin
intravenous (human)
Sandostatin, Lar Depot 25 mcg J2354
1 mg IM J2353
Sargramostim (GM-CSF) 50 mcg IV J2820
Sculptra 0.5 mg IV Q2028
Sebelelipase alfa 1 mg IV J2840
Selestoject per 4 mg IM, J0702
IV
Sermorelin acetate 1 mcg SC Q0515
Serostim 1 mg J2941
Signifor LAR 20 ml J2502
Siltuximab 10 mg IV J2860
Simponi Aria 1 mg J1602
Simulect 20 mg J0480
Sincalide 5 mcg IV J2805
Sinografin per ml Q9963
Sinusol-B per 10 mg IM, J0945
SC,
IV

Sirolimus 1 mg ORAL J7520

Sirolimus protien-bound 1 mg IM J9331 ◀
Sivextro 1 mg J3090
Skyla 13.5 mg OTH J7301
Smz-TMP J3490
Sodium Chloride 1,000 cc J7030
500 ml = 1 unit J7040
500 ml A4217
250 cc J7050
Bacteriostatic 10 ml A4216
Sodium Chloride Concentrate J7799
Sodium ferricgluconate in sucrose 12.5 mg J2916
Sodium Hyaluronate J3490
Euflexxa J7323
Hyalgan J7321
Orthovisc J7324
Solganal up to 50 mg IM J2910
Soliris 10 mg J1300
Solu-Cortef up to 50 mg IV, J1710
IM,
SC
100 mg J1720
Solu-Medrol up to 40 mg IM, J2920
IV
up to 125 mg IM, J2930
IV
Solurex 1 mg IM, J1100
IV,
OTH

Solurex LA 1 mg IM J1094
Somatrem 1 mg SC J2940
Somatropin 1 mg SC J2941
Somatulin Depot 1 mg J1930
Sparine up to 25 mg IM J2950
Spasmoject up to 20 mg IM J0500
Spectinomycin HCl up to 2 g IM J3320
Sporanox 50 mg IV J1835
Staphcillin, see Methicillin sodium
Stelara 1 mg J3357
Stilphostrol 250 mg IV J9165
Streptase 250,000 IU IV J2995
Streptokinase per 250,000 IU, IV J2995
Streptomycin up to 1 g IM J3000
Streptomycin Sulfate up to 1 g IM J3000
Streptozocin 1 gm IV J9320
Strontium-89 chloride per millicurie A9600
Sublimaze 0.1 mg IM, J3010
IV
Succinylcholine chloride up to 20 mg IV, IM J0330
Sufentanil Citrate J3490
Sumarel Dosepro 6 mg J3030
Sumatriptan succinate 6 mg SC J3030
Supartz OTH J7321
Supprelin LA 50 mg J9226
Surostrin up to 20 mg IV, IM J0330
Sus-Phrine up to 1 ml ampule SC, J0171
IM
Sutimlimab-jome 10 mg IM J1302 ◀
Susvimo 0.1 mg J2779 ◀
Synercid 500 mg (150/350) IV J2770
Synkavite per 1 mg IM, J3430
SC,
IV
Synribo 0.01 mg J9262
Syntocinon up to 10 units IV, IM J2590
Synvisc and Synvisc-One 1 mg OTH J7325
Syrex 10 ml A4216
Sytobex 1,000 mcg IM, J3420
SC
T
Tacrolimus
(Envarsus XR) 0.25 mg ORAL J7503
oral, extended release 0.1 mg ORAL J7508
oral, immediate release 1 mg ORAL J7507
parenteral 5 mg IV J7525
Tafasitamab 2 mg IV J9349
Tagraxofusp-erzs 10 mcg IV J9269
Taliglucerase Alfa 10 units IV J3060
Talimogene laherparepvec per 1 million IV J9325
plaque forming
units
Talwin 30 mg IM, J3070
SC,
IV
Tamoxifen Citrate J8999
Taractan, see Chlorprothixene
Taxol 1 mg IV J9267
Taxotere 20 mg IV J9171
Tazicef per 500 mg J0713
Tazidime, see Ceftazidime per dose A9500
Technetium TC Sestambi
J0713
Tebentafusp-tebn 1 mcg IM J9274 ◀
Tedizolid phosphate 1 mg IV J3090
TEEV 1 mg IM J3121
Teflaro 1 mg J0712
Telavancin 10 mg IV J3095
Temodar 5 mg ORAL J8700, J9328
Temozolomide 1 mg IV J9328
5 mg ORAL J8700
Temsirolimus 1 mg IV J9330
Tenecteplase 1 mg IV J3101
Teniposide 50 mg Q2017
Tepadina 15 mg J9340
Teprotumumab-trbw 10 mg IV J3241
Tequin 10 mg IV J1590
Terbutaline sulfate up to 1 mg SC, J3105
IV
concentrated form per 1 mg INH J7680
unit dose form per 1 mg INH J7681
Teriparatide 10 mcg SC J3110
Terramycin IM up to 50 mg IM J2460
Testa-C 1 mg J1071
Testadiate 1 mg IM J3121
Testadiate-Depo 1 mg J1071
Testaject-LA 1 mg J1071

Testaqua up to 50 mg IM J3140
Test-Estro Cypionates 1 mg J1071
Test-Estro-C 1 mg J1071
Testex up to 100 mg IM J3150
Testo AQ up to 50 mg J3140
Testoject-50 up to 50 mg IM J3140
Testoject-LA 1 mg J1071
Testone
LA 100 1 mg IM J3121
LA 200 1 mg IM J3121
Testopel Pellets J3490
Testosterone Aqueous up to 50 mg IM J3140
Testosterone cypionate 1 mg IM J1071
Testosterone enanthate 1 mg IM J3121
Testosterone undecanoate 1 mg IM J3145
Testradiol 90/4 1 mg IM J3121
Testrin PA 1 mg IM J3121
Testro AQ up to 50 mg J3140
Tetanus immune globulin, human up to 250 units IM J1670
Tetracycline up to 250 mg IM, J0120
IV
Tezepelumab-ekko 1 mg J2356 ◀
Thallous Chloride TI-201 per MCI A9505
Theelin Aqueous per 1 mg IM J1435
Theophylline per 40 mg IV J2810
Thiamine HCl 100 mg J3411
Thiethylperazine maleate
injection up to 10 mg IM J3280
oral 10 mg ORAL Q0174
Thiotepa 15 mg IV J9340
Thorazine up to 50 mg IM, J3230
IV
Thrombate III per IU J7197
Thymoglobulin (see also Immune
globulin)
anti-thymocyte globulin, equine 250 mg IV J7504
 anti-thymocyte globulin, rabbit 25 mg IV J7511
Thypinone per 250 mcg IV J2725
Thyrogen 0.9 mg IM, J3240
SC
Thyrotropin Alfa, injection 0.9 mg IM, J3240
SC
Ticon
injection up to 200 mg IM J3250
oral 250 mg ORAL Q0173
Tigan
injection up to 200 mg IM J3250
oral 250 mg ORAL Q0173
Tigecycline 1 mg IV J3243, J3244 ◀
Tiject-20
injection up to 200 mg IM J3250
oral 250 mg ORAL Q0173
Tinzaparin 1,000 IU SC J1655
Tirofiban Hydrochloride, injection 0.25 mg IM, J3246
IV
TNKase 1 mg IV J3101
Tobi 300 mg INH J7682, J7685
Tobramycin, inhalation solution 300 mg INH J7682, J7685
Tobramycin sulfate up to 80 mg IM, J3260
IV
Tocilizumab 1 mg IV J3262
Tofranil, see Imipramine HCl
Tolazoline HCl up to 25 mg IV J2670
Toposar 10 mg J9181
Topotecan 0.25 mg ORAL J8705
0.1 mg IV J9351
Toradol per 15 mg IM, J1885
IV
Torecan
injection up to 10 mg IM J3280
oral 10 mg ORAL Q0174
Torisel 1 mg J9330
Tornalate
concentrated form per mg INH J7628
unit dose per mg INH J7629
Torsemide 10 mg/ml IV J3265
Totacillin-N up to 500 mg IM, J0290
IV
per 1.5 gm IM, J0295
IV
Trabectedin 0.1 mg IV J9352
Trastuzumab 10 mg IV J9355
Trastuzumab-anns (kanjinti) 10 mg IV Q5117
Trastuzumab-dkst 10 mg IV Q5114
Trastuzumab-dttb 10 mg IV Q5112

Trastuzumab-pkrb 10 mg IV Q5113
Trastuzumab-qyyp (trazimera) 10 mg IV Q5116
Trastuzumab and Hyaluronidase 10 mg IV J9356
Treanda 1 mg IV J3490, J9033
Trelstar 3.75 mg J3315
Treprostinil 1 mg J3285, J7686
Trexall 2.5 mg ORAL J8610
Triam-A 1 mg J3300
per 10 mg IM J3301
Triamcinolone
 concentrated form per 1 mg INH J7683
unit dose per 1 mg INH J7684
Triamcinolone acetonide 1 mg J3300
per 10 mg IM J3301
Triamcinolone acetonide XR 1 mg IM J3304
Triamcinolone diacetate per 5 mg IM J3302
Triamcinolone hexacetonide per 5 mg VAR J3303
Triesence 1 mg J3300
per 10 mg IM J3301
Triethylene thio-Phosphoramide/T 15 mg J9340
Triflupromazine HCl up to 20 mg IM, J3400
IV
Tri-Kort 1 mg J3300
per 10 mg IM J3301
Trilaciclib 1 mg IV J1448
Trilafon 4 mg ORAL Q0175

up to 5 mg IM, J3310
IV
Trilog 1 mg J3300
per 10 mg IM J3301
Trilone per 5 mg J3302
Trimethobenzamide HCl
injection up to 200 mg IM J3250
oral 250 mg ORAL Q0173
Trimetrexate glucuronate per 25 mg IV J3305
Triptorelin Pamoate 3.75 mg SC J3315
Triptorelin XR 3.75 mg SC J3316
Trisenox 1 mg IV J9017
Trobicin up to 2 g IM J3320
Trovan 100 mg IV J0200
Tysabri 1 mg J2323
Tyvaso 1.74 mg J7686
U
Ultravist 240 per ml Q9966
Ultravist 300 per ml Q9967
Ultravist 370 per ml Q9967
Ultrazine-10 up to 10 mg IM, J0780
IV
Unasyn per 1.5 gm IM, J0295
IV
Unclassified drugs (see also Not J3490
elsewhere classified)
Unclassified drugs or biological used IV J3591
for ESRD on dialysis
Unspecified oral antiemetic Q0181
Urea up to 40 g IV J3350

Ureaphil up to 40 g IV J3350
Urecholine up to 5 mg SC J0520
Urofollitropin 75 IU J3355
Urokinase 5,000 IU vial IV J3364
250,000 IU vial IV J3365
Ustekinumab 1 mg SC J3357
1 mg IV J3358
V
Valcyte J3490
Valergen 10 10 mg IM J1380
Valergen 20 10 mg IM J1380
Valergen 40 up to 10 mg IM J1380
Valertest No. 1 1 mg IM J3121
Valertest No. 2 1 mg IM J3121
Valganciclovir HCL J8499
Valium up to 5 mg IM, J3360
IV
Valrubicin, intravesical 200 mg OTH J9357
Valstar 200 mg OTH J9357
Vancocin 500 mg IV, IM J3370
Vancoled 500 mg IV, IM J3370
Vancomycin HCl 500 mg IV, IM J3370, J3371, ◀
J3372
Vantas 50 mg J9226, J9225
Varubi 90 mg J8670
Vasceze per 10 mg J1642
Vasoxyl, see Methoxamine HCl
Vectibix 10 mg J9303
Vedolizumab 1 mg IV J3380
Velaglucerase alfa 100 units IV J3385
Velban 1 mg IV J9360
Velcade 0.1 mg J9041
Veletri 0.5 mg J1325
Velsar 1 mg IV J9360
Venofer 1 mg IV J1756
Ventavis 20 mcg Q4074
Ventolin 0.5 mg INH J7620
concentrated form 1 mg INH J7610, J7611
unit dose form 1 mg INH J7609, J7613
VePesid 50 mg ORAL J8560
Veritas Collagen Matrix J3490
Versed per 1 mg IM, J2250
IV
Verteporfin 0.1 mg IV J3396
Vesprin up to 20 mg IM, J3400
IV
Vestronidase alfa-vjbk 1 mg IV J3397
VFEND IV 10 mg IV J3465
V-Gan 25 up to 50 mg IM, J2550
IV
12.5 mg ORAL Q0169
V-Gan 50 up to 50 mg IM, J2550
IV
12.5 mg ORAL Q0169
Viadur 65 mg OTH J9219
Vibativ 10 mg J3095

Viltolarsen 10 mg IV J1427
Vinblastine sulfate 1 mg IV J9360
Vincasar PFS 1 mg IV J9370
Vincristine sulfate 1 mg IV J9370
Vincristine sulfate liposome 1 mg IV J9371
Vinorelbine tartrate per 10 mg IV J9390
Vispaque per ml Q9966,
Q9967
Vistaject-25 up to 25 mg IM J3410
Vistaril up to 25 mg IM J3410
25 mg ORAL Q0177
Vistide 375 mg IV J0740
Visudyne 0.1 mg IV J3396
Vitamin B-12 cyanocobalamin up to 1,000 mcg IM, J3420
 SC
Vitamin K, phytonadione, per 1 mg IM, J3430
menadione, menadiol sodium SC,
diphosphate IV
Vitrase per 1 USP unit J3471
Vivaglobin 100 mg J1562
Vivitrol 1 mg J2315
Von Willebrand Factor Complex, per IU VWF:RCo IV J7187
human
Wilate per IU VWF IV J7183
Vonvendi per IU VWF IV J7179
Voretigene neparvovec-rzyl 1 billion vector IV J3398
genomes
Voriconazole 10 mg IV J3465
Vpriv 100 units J3385
W
Wehamine up to 50 mg IM, J1240
IV
Wehdryl up to 50 mg IM, J1200
IV
50 mg ORAL Q0163
Wellcovorin per 50 mg IM, J0640
IV
Wilate per IU IV J7183
Win Rho SD 100 IU IV J2792
Wyamine Sulfate, see
Mephentermine sulfate
Wycillin up to 600,000 IM, J2510
units IV
Wydase up to 150 units SC, J3470
IV
X
Xeloda 150 mg ORAL J8520
500 mg ORAL J8521
Xeomin 1 unit J0588
Xgera 1 mg J0987
Xgeva 1 mg J0897
Xiaflex 0.01 mg J0775
Xipere 1 mg J3299 ◀
Xolair 5 mg J2357
Xopenex 0.5 mg INH J7620
concentrated form 1 mg INH J7610, J7611,
J7612
unit dose form 1 mg INH J7609, J7613,
J7614
Xylocaine HCl 10 mg IV J2001

Xyntha per IU IV J7185, J7192,

J7182, J7188
Y
Yervoy, see Ipilimumab
Yondelis 0.1 mg J9352, J9999
Z
Zaltrap 1 mg J9400
Zanosar 1g IV J9320
Zantac 25 mg IV, IM J2780
Zarxio 1 mcg Q5101
Zemaira 10 mg IV J0256
Zemplar 1 mcg IM, J2501
IV
Zenapax 25 mg IV J7513
Zerbaxa 1 gm J0695
Zetran up to 5 mg IM, J3360
IV
Ziconotide 1 mcg OTH J2278
Zidovudine 10 mg IV J3485
Zinacef per 750 mg IM, J0697
IV
Zinecard per 250 mg J1190
Ziprasidone Mesylate 10 mg IM J3486
Zithromax 1 gm ORAL Q0144
injection 500 mg IV J0456
Ziv-Aflibercept 1 mg IV J9400
Zmax 1g Q0144
Zofran 1 mg IV J2405

1 mg ORAL Q0162
Zoladex per 3.6 mg SC J9202
Zoledronic Acid 1 mg IV J3489
Zolicef 500 mg IV, IM J0690
Zometra 1 mg J3489
Zorbtive 1 mg J2941
Zortress 0.25 mg ORAL J7527
Zosyn 1.125 g IV J2543
Zovirax 5 mg J8499
Zyprexa Relprevv 1 mg J2358
Zyvox 200 mg IV J2020

◀ New Revised ✔ Reinstated deleted Deleted

 LEVEL II NATIONAL CODES
2023 HCPCS quarterly updates available on the companion
website at: http://www.codingupdates.com

DISCLAIMER
Every effort has been made to make this text complete and accurate, but no
guarantee, warranty, or representation is made for its accuracy or completeness.
This text is based on the Centers for Medicare and Medicaid Services Healthcare
Common Procedure Coding System (HCPCS).
Do not report HCPCS modifiers with MIPS CPT Category II codes, rather, use
Performance Measurement Modifiers 1P, 2P, 3P, and 8P, as instructed in the CPT
guidelines for Category II codes under ‘Modifiers’.

LEVEL II NATIONAL MODIFIERS

✽ A1 Dressing for one wound
✽ A2 Dressing for two wounds
✽ A3 Dressing for three wounds
✽ A4 Dressing for four wounds
✽ A5 Dressing for five wounds
✽ A6 Dressing for six wounds
✽ A7 Dressing for seven wounds
✽ A8 Dressing for eight wounds
✽ A9 Dressing for nine or more wounds
❂ AA Anesthesia services performed personally by anesthesiologist
IOM: 100-04, 12, 90.4
▶ AB Audiology service furnished personally by an audiologist without
a physician/npp order for non-acute hearing assessment unrelated
to disequilibrium, or hearing aids, or examinations for the
purpose of prescribing, fitting, or changing hearing aids; service
may be performed once every 12 months, per beneficiary
❂ AD Medical supervision by a physician: more than four concurrent
anesthesia procedures
IOM: 100-04, 12, 90.4
✽ AE Registered dietician
✽ AF Specialty physician
✽ AG Primary physician
❂ AH Clinical psychologist
IOM: 100-04, 12, 170
✽ AI Principal physician of record
❂ AJ Clinical social worker
IOM: 100-04, 12, 170; 100-04, 12, 150
✽ AK Nonparticipating physician
❂ AM Physician, team member service
Not assigned for Medicare
Cross Reference QM
✽ AO Alternate payment method declined by provider of service
✽ AP Determination of refractive state was not performed in the course
of diagnostic ophthalmological examination
✽ AQ Physician providing a service in an unlisted health professional
shortage area (HPSA)
✽ AR Physician provider services in a physician scarcity area
✽ AS Physician assistant, nurse practitioner, or clinical nurse specialist
services for assistant at surgery
✽ AT Acute treatment (this modifier should be used when reporting
service 98940, 98941, 98942)
✽ AU Item furnished in conjunction with a urological, ostomy, or
tracheostomy supply
✽ AV Item furnished in conjunction with a prosthetic device, prosthetic
or orthotic
✽ AW Item furnished in conjunction with a surgical dressing
✽ AX Item furnished in conjunction with dialysis services
✽ AY Item or service furnished to an ESRD patient that is not for the
treatment of ESRD
AZ Physician providing a service in a dental health professional
shortage area for the purpose of an electronic health record
incentive payment
✽ BA Item furnished in conjunction with parenteral enteral nutrition
(PEN) services
✽ BL Special acquisition of blood and blood products
✽ BO Orally administered nutrition, not by feeding tube
✽ BP The beneficiary has been informed of the purchase and rental
options and has elected to purchase the item
✽ BR The beneficiary has been informed of the purchase and rental
options and has elected to rent the item
✽ BU The beneficiary has been informed of the purchase and rental
options and after 30 days has not informed the supplier of his/her
decision
✽ CA Procedure payable only in the inpatient setting when performed
emergently on an outpatient who expires prior to admission
✽ CB Service ordered by a renal dialysis facility (RDF) physician as
part of the ESRD beneficiary’s dialysis benefit, is not part of the
composite rate, and is separately reimbursable
✽ CC Procedure code change (Use CC when the procedure code
submitted was changed either for administrative reasons or
because an incorrect code was filed)
❂ CD AMCC test has been ordered by an ESRD facility or MCP
physician that is part of the composite rate and is not separately
billable
❂ CE AMCC test has been ordered by an ESRD facility or MCP
physician that is a composite rate test but is beyond the normal
frequency covered under the rate and is separately reimbursable
based on medical necessity
❂ CF AMCC test has been ordered by an ESRD facility or MCP
physician that is not part of the composite rate and is separately
billable
✽ CG Policy criteria applied
❂ CH 0 percent impaired, limited or restricted
❂ CI At least 1 percent but less than 20 percent impaired, limited or
restricted
❂ CJ At least 20 percent but less than 40 percent impaired, limited or
restricted
❂ CK At least 40 percent but less than 60 percent impaired, limited or
restricted
❂ CL At least 60 percent but less than 80 percent impaired, limited or
restricted
❂ CM At least 80 percent but less than 100 percent impaired, limited or
restricted
❂ CN 100 percent impaired, limited or restricted
✽ CO Outpatient occupational therapy services furnished in whole or in
part by an occupational therapy assistant
✽ CR Catastrophe/Disaster related
✽ CS Cost-sharing waived for specified covid-19 testing-related
services that result in and order for or administration of a covid-
19 test and/or used for cost-sharing waived preventive services
 furnished via telehealth in rural health clinics and federally
qualified health centers during the covid-19 public health
emergency
✽ CT Computed tomography services furnished using equipment that
does not meet each of the attributes of the national electrical
manufacturers association (NEMA) XR-29-2013 standard
Coding Clinic: 2017, Q1, P6
✽ CQ Outpatient physical therapy services furnished in whole or in part
by a physical therapist assistant
✽ DA Oral health assessment by a licensed health professional other
than a dentist
✽ E1 Upper left, eyelid
Coding Clinic: 2016, Q3, P3
✽ E2 Lower left, eyelid
Coding Clinic: 2016, Q3, P3
✽ E3 Upper right, eyelid
Coding Clinic: 2011, Q3, P6
✽ E4 Lower right, eyelid
❂ EA Erythropoetic stimulating agent (ESA) administered to treat
anemia due to anti-cancer chemotherapy
CMS requires claims for non-ESRD ESAs (J0881 and J0885) to
include one of three modifiers: EA, EB, EC.
❂ EB Erythropoetic stimulating agent (ESA) administered to treat
anemia due to anti-cancer radiotherapy
CMS requires claims for non-ESRD ESAs (J0881 and J0885) to
include one of three modifiers: EA, EB, EC.
❂ EC Erythropoetic stimulating agent (ESA) administered to treat
anemia not due to anti-cancer radiotherapy or anti-cancer
chemotherapy
CMS requires claims for non-ESRD ESAs (J0881 and J0885) to
include one of three modifiers: EA, EB, EC.
❂ ED Hematocrit level has exceeded 39% (or hemoglobin level has
exceeded 13.0 g/dl) for 3 or more consecutive billing cycles
immediately prior to and including the current cycle
❂ EE Hematocrit level has not exceeded 39% (or hemoglobin level has
not exceeded 13.0 g/dl) for 3 or more consecutive billing cycles
immediately prior to and including the current cycle
❂ EJ Subsequent claims for a defined course of therapy, e.g., EPO,
 sodium hyaluronate, infliximab
❂ EM Emergency reserve supply (for ESRD benefit only)
✽ EP Service provided as part of Medicaid early periodic screening
diagnosis and treatment (EPSDT) program
✽ ER Items and services furnished by a provider-based, off-campus
emergency department
✽ ET Emergency services
✽ EX Expatriate beneficiary
✽ EY No physician or other licensed health care provider order for this
item or service
Items billed before a signed and dated order has been received by
the supplier must be submitted with an EY modifier added to each
related HCPCS code.
✽ F1 Left hand, second digit
✽ F2 Left hand, third digit
✽ F3 Left hand, fourth digit
✽ F4 Left hand, fifth digit
✽ F5 Right hand, thumb
✽ F6 Right hand, second digit
✽ F7 Right hand, third digit
✽ F8 Right hand, fourth digit
✽ F9 Right hand, fifth digit
✽ FA Left hand, thumb
FB Item provided without cost to provider, supplier or practitioner, or
full credit received for replaced device (examples, but not limited
to, covered under warranty, replaced due to defect, free samples)
❂ FC Partial credit received for replaced device
✽ FP Service provided as part of family planning program
✽ FQ The service was furnished using audio-only communication
technology
✽ FR The supervising practitioner was present through two-way,
audio/video communication technology

✽ FS Split (or shared) evaluation and management visit

✽ FT Unrelated evaluation and management (e/m) visit during a
 postoperative period, or on the same day as a procedure or
another E/M visit. (report when an e/m visit is furnished within
the global period but is unrelated, or when one or more additional
E/M visits furnished on the same day are unrelated)
✽ FX X-ray taken using film
Coding Clinic: 2017, Q1, P6
✽ FY X-ray taken using computed radiography technology/cassette-
based imaging
✽ G0 Telehealth services for diagnosis, evaluation, or treatment, of
symptoms of an acute stroke
✽ G1 Most recent URR reading of less than 60
IOM: 100-04, 8, 50.9
✽ G2 Most recent URR reading of 60 to 64.9
IOM: 100-04, 8, 50.9
✽ G3 Most recent URR reading of 65 to 69.9
IOM: 100-04, 8, 50.9
✽ G4 Most recent URR reading of 70 to 74.9
IOM: 100-04, 8, 50.9
✽ G5 Most recent URR reading of 75 or greater
IOM: 100-04, 8, 50.9
✽ G6 ESRD patient for whom less than six dialysis sessions have been
provided in a month
IOM: 100-04, 8, 50.9
❂ G7 Pregnancy resulted from rape or incest or pregnancy certified by
physician as life threatening
IOM: 100-02, 15, 20.1; 100-03, 3, 170.3
✽ G8 Monitored anesthesia care (MAC) for deep complex,
complicated, or markedly invasive surgical procedure
✽ G9 Monitored anesthesia care for patient who has history of severe
cardiopulmonary condition
✽ GA Waiver of liability statement issued as required by payer policy,
individual case
An item/service is expected to be denied as not reasonable and
necessary and an ABN is on file. Modifier GA can be used on
either a specific or a miscellaneous HCPCS code. Modifiers GA
and GY should never be reported together on the same line for the
same HCPCS code.
✽ GB Claim being resubmitted for payment because it is no longer
covered under a global payment demonstration
❂ GC This service has been performed in part by a resident under the
direction of a teaching physician
IOM: 100-04, 12, 90.4, 100
❂ GE This service has been performed by a resident without the
presence of a teaching physician under the primary care exception
✽ GF Non-physician (e.g., nurse practitioner (NP), certified registered
nurse anesthetist (CRNA), certified registered nurse (CRN),
clinical nurse specialist (CNS), physician assistant (PA)) services
in a critical access hospital
✽ GG Performance and payment of a screening mammogram and
diagnostic mammogram on the same patient, same day
✽ GH Diagnostic mammogram converted from screening mammogram
on same day
✽ GJ “Opt out” physician or practitioner emergency or urgent service
✽ GK Reasonable and necessary item/service associated with a GA or
GZ modifier
An upgrade is defined as an item that goes beyond what is
medically necessary under Medicare’s coverage requirements. An
item can be considered an upgrade even if the physician has
signed an order for it. When suppliers know that an item will not
be paid in full because it does not meet the coverage criteria
stated in the LCD, the supplier can still obtain partial payment at
the time of initial determination if the claim is billed using one of
the upgrade modifiers (GK or GL).
(https://www.cms.gov/manuals/downloads/clm104c01.pdf)
✽ GL Medically unnecessary upgrade provided instead of non-upgraded
item, no charge, no Advance Beneficiary Notice (ABN)
✽ GM Multiple patients on one ambulance trip
✽ GN Services delivered under an outpatient speech language pathology
plan of care
✽ GO Services delivered under an outpatient occupational therapy plan
of care
✽ GP Services delivered under an outpatient physical therapy plan of
care
✽ GQ Via asynchronous telecommunications system
✽ GR This service was performed in whole or in part by a resident in a
Department of Veterans Affairs medical center or clinic,
supervised in accordance with VA policy
❂ GS Dosage of erythropoietin-stimulating agent has been reduced and
maintained in response to hematocrit or hemoglobin level
❂ GT Via interactive audio and video telecommunication systems
✽ GU Waiver of liability statement issued as required by payer policy,
routine notice
❂ GV Attending physician not employed or paid under arrangement by
the patient’s hospice provider
❂ GW Service not related to the hospice patient’s terminal condition
✽ GX Notice of liability issued, voluntary under payer policy
GX modifier must be submitted with non-covered charges only.
This modifier differentiates from the required uses in conjunction
with ABN.
(https://www.cms.gov/manuals/downloads/clm104c01.pdf)
GY Item or service statutorily excluded, does not meet the definition
of any Medicare benefit or, for non-Medicare insurers, is not a
contract benefit
Examples of “statutorily excluded” include: Infusion drug not
administered using a durable infusion pump, a wheelchair that is
for use for mobility outside the home or hearing aids. GA and GY
should never be coded together on the same line for the same
HCPCS code.
(https://www.cms.gov/manuals/downloads/clm104c01.pdf)
GZ Item or service expected to be denied as not reasonable or
necessary
Used when an ABN is not on file and can be used on either a
specific or a miscellaneous HCPCS code. It would never be
correct to place any combination of GY, GZ or GA modifiers on
the same claim line and will result in rejected or denied claim for
invalid coding.
(https://www.cms.gov/manuals/downloads/clm104c01.pdf)

H9 Court-ordered
HA Child/adolescent program
HB Adult program, nongeriatric
HC Adult program, geriatric
HD Pregnant/parenting women’s program
HE Mental health program
HF Substance abuse program
HG Opioid addiction treatment program
HH Integrated mental health/substance abuse program
HI Integrated mental health and intellectual disability/developmental
disabilities program
HJ Employee assistance program
HK Specialized mental health programs for high-risk populations
HL Intern
HM Less than bachelors degree level
HN Bachelors degree level
HO Masters degree level
HP Doctoral level
HQ Group setting
HR Family/couple with client present
HS Family/couple without client present
HT Multi-disciplinary team
HU Funded by child welfare agency
HV Funded by state addictions agency
HW Funded by state mental health agency
HX Funded by county/local agency
HY Funded by juvenile justice agency
HZ Funded by criminal justice agency
✽ J1 Competitive acquisition program nopay submission for a
prescription number

✽ J2 Competitive acquisition program, restocking of emergency drugs

after emergency administration
✽ J3 Competitive acquisition program (CAP), drug not available
through CAP as written, reimbursed under average sales price
methodology
✽ J4 DMEPOS item subject to DMEPOS competitive bidding program
that is furnished by a hospital upon discharge
✽ J5 Off-the-shelf orthotic subject to dmepos competitive bidding
program that is furnished as part of a physical therapist or
occupational therapist professional service
✽ JA Administered intravenously
This modifier is informational only (not a payment modifier) and
may be submitted with all injection codes. According to
Medicare, reporting this modifier is voluntary. (CMS Pub. 100-
04, chapter 8, section 60.2.3.1 and Pub. 100-04, chapter 17,
section 80.11)
✽ JB Administered subcutaneously
✽ JC Skin substitute used as a graft
✽ JD Skin substitute not used as a graft
✽ JE Administered via dialysate
✽ JG Drug or biological acquired with 340B drug pricing program
discount, reported for informational purposes
✽ JW Drug amount discarded/not administered to any patient
Use JW to identify unused drugs or biologicals from single use
vial/package that are appropriately discarded. Bill on separate line
for payment of discarded drug/biological.
IOM: 100-4, 17, 40
Coding Clinic: 2016, Q4, P4-7; 2010, Q3, P10
▶ JZ Zero drug amount discarded/not administered to any patient
✽ K0 Lower extremity prosthesis functional Level 0 - does not have the
ability or potential to ambulate or transfer safely with or without
assistance and a prosthesis does not enhance their quality of life
or mobility.
✽ K1 Lower extremity prosthesis functional Level 1 - has the ability or
potential to use a prosthesis for transfers or ambulation on level
surfaces at fixed cadence. Typical of the limited and unlimited
household ambulator.

✽ K2 Lower extremity prosthesis functional Level 2 - has the ability or

potential for ambulation with the ability to traverse low level
environmental barriers such as curbs, stairs or uneven surfaces.
Typical of the limited community ambulator.
✽ K3 Lower extremity prosthesis functional Level 3 - has the ability or
potential for ambulation with variable cadence. Typical of the
community ambulator who has the ability to traverse most
 environmental barriers and may have vocational, therapeutic, or
exercise activity that demands prosthetic utilization beyond
simple locomotion.
✽ K4 Lower extremity prosthesis functional Level 4 - has the ability or
potential for prosthetic ambulation that exceeds the basic
ambulation skills, exhibiting high impact, stress, or energy levels,
typical of the prosthetic demands of the child, active adult, or
athlete.
✽ KA Add on option/accessory for wheelchair
✽ KB Beneficiary requested upgrade for ABN, more than 4 modifiers
identified on claim
✽ KC Replacement of special power wheelchair interface
✽ KD Drug or biological infused through DME
✽ KE Bid under round one of the DMEPOS competitive bidding
program for use with non-competitive bid base equipment
✽ KF Item designated by FDA as Class III device
✽ KG DMEPOS item subject to DMEPOS competitive bidding program
number 1
✽ KH DMEPOS item, initial claim, purchase or first month rental
✽ KI DMEPOS item, second or third month rental
✽ KJ DMEPOS item, parenteral enteral nutrition (PEN) pump or
capped rental, months four to fifteen
✽ KK DMEPOS item subject to DMEPOS competitive bidding program
number 2
✽ KL DMEPOS item delivered via mail
✽ KM Replacement of facial prosthesis including new
impression/moulage
✽ KN Replacement of facial prosthesis using previous master model
✽ KO Single drug unit dose formulation
✽ KP First drug of a multiple drug unit dose formulation
✽ KQ Second or subsequent drug of a multiple drug unit dose
formulation
✽ KR Rental item, billing for partial month
❂ KS Glucose monitor supply for diabetic beneficiary not treated with
insulin
✽ KT Beneficiary resides in a competitive bidding area and travels
 outside that competitive bidding area and receives a competitive
bid item
✽ KU DMEPOS item subject to DMEPOS competitive bidding program
number 3
✽ KV DMEPOS item subject to DMEPOS competitive bidding program
that is furnished as part of a professional service
✽ KW DMEPOS item subject to DMEPOS competitive bidding program
number 4
✽ KX Requirements specified in the medical policy have been met
Used for physical, occupational, or speech-language therapy to
request an exception to therapy payment caps and indicate the
services are reasonable and necessary and that there is
documentation of medical necessity in the patient’s medical
record. (Pub 100-04 Attachment - Business Requirements Centers
for Medicare and Medicaid Services, Transmittal 2457, April 27,
2012)
Medicare requires modifier KX for implanted permanent cardiac
pacemakers, single chamber or duel chamber, for one of the
following CPT codes: 33206, 33207, 33208.
✽ KY DMEPOS item subject to DMEPOS competitive bidding program
number 5
✽ KZ New coverage not implemented by managed care
✽ LC Left circumflex coronary artery
✽ LD Left anterior descending coronary artery
✽ LL Lease/rental (use the LL modifier when DME equipment rental is
to be applied against the purchase price)
✽ LM Left main coronary artery

✽ LR Laboratory round trip

❂ LS FDA-monitored intraocular lens implant
✽ LT Left side (used to identify procedures performed on the left side
of the body)
Modifiers LT and RT identify procedures which can be performed
on paired organs. Used for procedures performed on one side
only. Should also be used when the procedures are similar but not
identical and are performed on paired body parts.
Coding Clinic: 2016, Q3, P5
▶ LU Fractionated payment of CAR-T therapy
✽ M2 Medicare secondary payer (MSP)
✽ MA Ordering professional is not required to consult a clinical decision
support mechanism due to service being rendered to a patient
with a suspected or confirmed emergency medical condition
✽ MB Ordering professional is not required to consult a clinical decision
support mechanism due to the significant hardship exception of
insufficient internet access
✽ MC Ordering professional is not required to consult a clinical decision
support mechanism due to the significant hardship exception of
electronic health record or clinical decision support mechanism
vendor issues
✽ MD Ordering professional is not required to consult a clinical decision
support mechanism due to the significant hardship exception of
extreme and uncontrollable circumstances
✽ ME The order for this service adheres to appropriate use criteria in the
clinical decision support mechanism consulted by the ordering
professional
✽ MF The order for this service does not adhere to the appropriate use
criteria in the clinical decision support mechanism consulted by
the ordering professional
✽ MG The order for this service does not have applicable appropriate
use criteria in the qualified clinical decision support mechanism
consulted by the ordering professional
✽ MH Unknown if ordering professional consulted a clinical decision
support mechanism for this service, related information was not
provided to the furnishing professional or provider

✽ MS Six month maintenance and servicing fee for reasonable and

necessary parts and labor which are not covered under any
manufacturer or supplier warranty
✽ NB Nebulizer system, any type, FDA-cleared for use with specific
drug
✽ NR New when rented (use the NR modifier when DME which was
new at the time of rental is subsequently purchased)
✽ NU New equipment
✽ P1 A normal healthy patient
✽ P2 A patient with mild systemic disease
✽ P3 A patient with severe systemic disease
✽ P4 A patient with severe systemic disease that is a constant threat to
life
✽ P5 A moribund patient who is not expected to survive without the
operation
✽ P6 A declared brain-dead patient whose organs are being removed
for donor purposes
PA Surgical or other invasive procedure on wrong body part
PB Surgical or other invasive procedure on wrong patient
PC Wrong surgery or other invasive procedure on patient
✽ PD Diagnostic or related non diagnostic item or service provided in a
wholly owned or operated entity to a patient who is admitted as
an inpatient within 3 days
✽ PI Positron emission tomography (PET) or PET/computed
tomography (CT) to inform the initial treatment strategy of
tumors that are biopsy proven or strongly suspected of being
cancerous based on other diagnostic testing
✽ PL Progressive addition lenses
✽ PM Post mortem
✽ PN Non-excepted service provided at an off-campus, outpatient,
provider-based department of a hospital
✽ PO Expected services provided at off-campus, outpatient, provider-
based department of a hospital
✽ PS Positron emission tomography (PET) or PET/computed
tomography (CT) to inform the subsequent treatment strategy of
cancerous tumors when the beneficiary’s treating physician
determines that the PET study is needed to inform subsequent
antitumor strategy

✽ PT Colorectal cancer screening test; converted to diagnostic text or

other procedure
Assign this modifier with the appropriate CPT procedure code for
colonoscopy, flexible sigmoidoscopy, or barium enema when the
service is initiated as a colorectal cancer screening service but
then becomes a diagnostic service. MLN Matters article MM7012
(PDF, 75 KB) Reference Medicare Transmittal 3232 April 3,
2015.
Coding Clinic: 2011, Q1, P10
❂ Q0 Investigational clinical service provided in a clinical research
 study that is in an approved clinical research study
❂ Q1 Routine clinical service provided in a clinical research study that
is in an approved clinical research study
✽ Q2 Demonstration procedure/service
✽ Q3 Live kidney donor surgery and related services
✽ Q4 Service for ordering/referring physician qualifies as a service
exemption
❂ Q5 Service furnished under a reciprocal billing arrangement by a
substitute physician or by a substitute physical therapist
furnishing outpatient physical therapy services in a health
professional shortage area, a medically underserved area, or a
rural area
IOM: 100-04, 1, 30.2.10
❂ Q6 Service furnished under a fee-for-time compensation arrangement
by a substitute physician or by a substitute physical therapist
furnishing outpatient physical therapy services in a health
professional shortage area, a medically underserved area, or a
rural area
IOM: 100-04, 1, 30.2.11
✽ Q7 One Class A finding
✽ Q8 Two Class B findings
✽ Q9 One Class B and two Class C findings
✽ QA Prescribed amounts of stationary oxygen for daytime use while at
rest and nighttime use differ and the average of the two amounts
is less than 1 liter per minute (lpm)

✽ QB Prescribed amounts of stationary oxygen for daytime use while at

rest and nighttime use differ and the average of the two amounts
exceeds 4 liters per minute (lpm) and portable oxygen is
prescribed
✽ QC Single channel monitoring
✽ QD Recording and storage in solid state memory by a digital recorder
✽ QE Prescribed amount of stationary oxygen while at rest is less than 1
liter per minute (LPM)
✽ QF Prescribed amount of stationary oxygen while at rest exceeds 4
liters per minute (LPM) and portable oxygen is prescribed
✽ QG Prescribed amount of stationary oxygen while at rest is greater
 than 4 liters per minute (LPM)
✽ QH Oxygen conserving device is being used with an oxygen delivery
system
❂ QJ Services/items provided to a prisoner or patient in state or local
custody, however, the state or local government, as applicable,
meets the requirements in 42 CFR 411.4 (B)
❂ QK Medical direction of two, three, or four concurrent anesthesia
procedures involving qualified individuals
IOM: 100-04, 12, 50K, 90
✽ QL Patient pronounced dead after ambulance called
✽ QM Ambulance service provided under arrangement by a provider of
services
✽ QN Ambulance service furnished directly by a provider of services
❂ QP Documentation is on file showing that the laboratory test(s) was
ordered individually or ordered as a CPT-recognized panel other
than automated profile codes 80002-80019, G0058, G0059, and
G0060
✽ QQ Ordering professional consulted a qualified clinical decision
support mechanism for this service and the related data was
provided to the furnishing professional
✽ QR Prescribed amounts of stationary oxygen for daytime use while at
rest and nighttime use differ and the average of the two amounts
is greater than 4 liters per minute (lpm)

❂ QS Monitored anesthesia care service

IOM: 100-04, 12, 30.6, 501
✽ QT Recording and storage on tape by an analog tape recorder
✽ QW CLIA-waived test
✽ QX CRNA service: with medical direction by a physician
❂ QY Medical direction of one certified registered nurse anesthetist
(CRNA) by an anesthesiologist
IOM: 100-04, 12, 50K, 90
✽ QZ CRNA service: without medical direction by a physician
✽ RA Replacement of a DME, orthotic or prosthetic item
Contractors will deny claims for replacement parts when
furnished in conjunction with the repair of a capped rental item
and billed with modifier RB, including claims for parts submitted
 using code E1399, that are billed during the capped rental period
(i.e., the last day of the 13th month of continuous use or before).
Repair includes all maintenance, servicing, and repair of capped
rental DME because it is included in the allowed rental payment
amounts. (Pub 100-20 One-Time Notification Centers for
Medicare &amp; Medicaid Services, Transmittal: 901, May 13,
2011)
✽ RB Replacement of a part of a DME, orthotic or prosthetic item
furnished as part of a repair
✽ RC Right coronary artery
✽ RD Drug provided to beneficiary, but not administered “incident-to”
✽ RE Furnished in full compliance with FDA-mandated risk evaluation
and mitigation strategy (REMS)
✽ RI Ramus intermedius coronary artery
✽ RR Rental (use the ‘RR’ modifier when DME is to be rented)
✽ RT Right side (used to identify procedures performed on the right
side of the body)
Modifiers LT and RT identify procedures which can be performed
on paired organs. Used for procedures performed on one side
only. Should also be used when the procedures are similar but not
identical and are performed on paired body parts.
Coding Clinic: 2016, Q3, P5
SA Nurse practitioner rendering service in collaboration with a
physician
SB Nurse midwife
✽ SC Medically necessary service or supply
SD Services provided by registered nurse with specialized, highly
technical home infusion training
SE State and/or federally funded programs/services
✽ SF Second opinion ordered by a professional review organization
(PRO) per Section 9401, P.L. 99-272 (100% reimbursement – no
Medicare deductible or coinsurance)
✽ SG Ambulatory surgical center (ASC) facility service
Only valid for surgical codes. After 1/1/08 not required for ASC
facility charges.
SH Second concurrently administered infusion therapy
SJ Third or more concurrently administered infusion therapy
SK Member of high risk population (use only with codes for
immunization)
SL State supplied vaccine
SM Second surgical opinion
SN Third surgical opinion
SQ Item ordered by home health
SS Home infusion services provided in the infusion suite of the IV
therapy provider
ST Related to trauma or injury
SU Procedure performed in physician’s office (to denote use of
facility and equipment)
SV Pharmaceuticals delivered to patient’s home but not utilized
✽ SW Services provided by a certified diabetic educator
SY Persons who are in close contact with member of high-risk
population (use only with codes for immunization)
✽ T1 Left foot, second digit
✽ T2 Left foot, third digit
✽ T3 Left foot, fourth digit
✽ T4 Left foot, fifth digit

✽ T5 Right foot, great toe

✽ T6 Right foot, second digit
✽ T7 Right foot, third digit
✽ T8 Right foot, fourth digit
✽ T9 Right foot, fifth digit
✽ TA Left foot, great toe
✽ TB Drug or biological acquired with 340B drug pricing program
discount, reported for informational purposes for select entities
✽ TC Technical component; under certain circumstances, a charge may
be made for the technical component alone; under those
circumstances the technical component charge is identified by
adding modifier TC to the usual procedure number; technical
component charges are institutional charges and not billed
separately by physicians; however, portable x-ray suppliers only
bill for technical component and should utilize modifier TC; the
charge data from portable x-ray suppliers will then be used to
 build customary and prevailing profiles.
TD RN
TE LPN/LVN
TF Intermediate level of care
TG Complex/high tech level of care
TH Obstetrical treatment/services, prenatal or postpartum
TJ Program group, child and/or adolescent
TK Extra patient or passenger, nonambulance
TL Early intervention/individualized family service plan (IFSP)
TM Individualized education program (IEP)
TN Rural/outside providers’ customary service area
TP Medical transport, unloaded vehicle
TQ Basic life support transport by a volunteer ambulance provider
TR School-based individual education program (IEP) services
provided outside the public school district responsible for the
student

✽ TS Follow-up service
TT Individualized service provided to more than one patient in same
setting
TU Special payment rate, overtime
TV Special payment rates, holidays/weekends
TW Back-up equipment
U1 Medicaid Level of Care 1, as defined by each State
U2 Medicaid Level of Care 2, as defined by each State
U3 Medicaid Level of Care 3, as defined by each State
U4 Medicaid Level of Care 4, as defined by each State
U5 Medicaid Level of Care 5, as defined by each State
U6 Medicaid Level of Care 6, as defined by each State
U7 Medicaid Level of Care 7, as defined by each State
U8 Medicaid Level of Care 8, as defined by each State
U9 Medicaid Level of Care 9, as defined by each State
UA Medicaid Level of Care 10, as defined by each State
UB Medicaid Level of Care 11, as defined by each State
UC Medicaid Level of Care 12, as defined by each State
UD Medicaid Level of Care 13, as defined by each State
✽ UE Used durable medical equipment
UF Services provided in the morning
UG Services provided in the afternoon
UH Services provided in the evening
✽ UJ Services provided at night
UK Services provided on behalf of the client to someone other than
the client (collateral relationship)
✽ UN Two patients served
✽ UP Three patients served
✽ UQ Four patients served
✽ UR Five patients served
✽ US Six or more patients served
✽ V1 Demonstration Modifier 1
✽ V2 Demonstration Modifier 2

✽ V3 Demonstration Modifier 3
✽ V4 Demonstration modifier 4
✽ V5 Vascular catheter (alone or with any other vascular access)
✽ V6 Arteriovenous graft (or other vascular access not including a
vascular catheter)
✽ V7 Arteriovenous fistula only (in use with two needles)
✽ VM Medicare diabetes prevention program (MDPP) virtual make-up
session
✽ VP Aphakic patient
✽ X1 Continuous/broad services: for reporting services by clinicians,
who provide the principal care for a patient, with no planned
endpoint of the relationship; services in this category represent
comprehensive care, dealing with the entire scope of patient
problems, either directly or in a care coordination role; reporting
clinician service examples include, but are not limited to: primary
care, and clinicians providing comprehensive care to patients in
addition to specialty care
✽ X2 Continuous/focused services: for reporting services by clinicians
whose expertise is needed for the ongoing management of a
chronic disease or a condition that needs to be managed and
followed with no planned endpoint to the relationship; reporting
clinician service examples include but are not limited to: a
rheumatologist taking care of the patient’s rheumatoid arthritis
longitudinally but not providing general primary care services
✽ X3 Episodic/broad services: for reporting services by clinicians who
have broad responsibility for the comprehensive needs of the
patient that is limited to a defined period and circumstance such
as a hospitalization; reporting clinician service examples include
but are not limited to the hospitalist’s services rendered providing
comprehensive and general care to a patient while admitted to the
hospital
✽ X4 Episodic/focused services: for reporting services by clinicians
who provide focused care on particular types of treatment limited
to a defined period and circumstance; the patient has a problem,
acute or chronic, that will be treated with surgery, radiation, or
some other type of generally time-limited intervention; reporting
clinician service examples include but are not limited to, the
orthopedic surgeon performing a knee replacement and seeing the
patient through the postoperative period
✽ X5 Diagnostic services requested by another clinician: for reporting
services by a clinician who furnishes care to the patient only as
requested by another clinician or subsequent and related services
requested by another clinician; this modifier is reported for
patient relationships that may not be adequately captured by the
above alternative categories; reporting clinician service examples
include but are not limited to, the radiologist’s interpretation of an
imaging study requested by another clinician
✽ XE Separate encounter, a service that is distinct because it occurred
during a separate encounter
✽ XP Separate practitioner, a service that is distinct because it was
performed by a different practitioner
✽ XS Separate structure, a service that is distinct because it was
performed on a separate organ/structure
✽ XU Unusual non-overlapping service, the use of a service that is
distinct because it does not overlap usual components of the main
service
Ambulance Modifiers
Modifiers that are used on claims for ambulance services are created by
combining two alpha characters. Each alpha character, with the exception of X,
represents an origin (source) code or a destination code. The pair of alpha codes
creates one modifier. The first position alpha-code = origin; the second position
alpha-code = destination. On form CMS-1491, used to report ambulance
services, Item 12 should contain the origin code and Item 13 should contain the
destination code. Origin and destination codes and their descriptions are as
follows:

D Diagnostic or therapeutic site other than P or H when these are used as

origin codes
E Residential, domiciliary, custodial facility (other than an 1819 facility)
G Hospital-based ESRD facility
H Hospital
I Site of transfer (e.g., airport or helicopter pad) between modes of
ambulance transport
J Freestanding ESRD facility
N Skilled nursing facility
P Physician’s office
R Residence
S Scene of accident or acute event
X Intermediate stop at physician’s office on way to hospital (destination code
only)

◀ New Revised ✔ Reinstated deleted Deleted Not covered or valid by Medicare ❂ Special

coverage instructions ✽ Carrier discretion Bill Part B MAC Bill DME MAC MIPS

Quantity Physician Quantity Hospital ♀ Female only ♂ Male only Age

DMEPOS A2-Z3 ASC Payment Indicator A-Y ASC Status Indicator Coding Clinic
TRANSPORT SERVICES INCLUDING AMBULANCE
(A0000-A0999)
A0021 Ambulance service, outside state per mile, transport (Medicaid only)
E1

Cross Reference A0030

A0080 Non-emergency transportation, per mile - vehicle provided by
volunteer (individual or organization), with no vested interest
E1
A0090 Non-emergency transportation, per mile - vehicle provided by
individual (family member, self, neighbor) with vested interest
E1
A0100 Non-emergency transportation; taxi E1

A0110 Non-emergency transportation and bus, intra- or interstate carrier

E1

A0120 Non-emergency transportation: mini-bus, mountain area transports,

or other transportation systems E1

A0130 Non-emergency transportation: wheelchair van E1

A0140 Non-emergency transportation and air travel (private or

commercial), intra- or interstate E1

A0160 Non-emergency transportation: per mile - caseworker or social

worker E1

A0170 Transportation: ancillary: parking fees, tolls, other E1

A0180 Non-emergency transportation: ancillary: lodging - recipient

E1
A0190 Non-emergency transportation: ancillary: meals - recipient
E1
A0200 Non-emergency transportation: ancillary: lodging - escort
E1
A0210 Non-emergency transportation: ancillary: meals - escort
E1
A0225 Ambulance service, neonatal transport, base rate, emergency
transport, one way E1

A0380 BLS mileage (per mile) E1

Cross Reference A0425

A0382 BLS routine disposable supplies E1

A0384 BLS specialized service disposable supplies; defibrillation (used by

 ALS ambulances and BLS ambulances in jurisdictions where
defibrillation is permitted in BLS ambulances) E1

A0390 ALS mileage (per mile) E1

Cross Reference A0425

A0392 ALS specialized service disposable supplies; defibrillation (to be
used only in jurisdictions where defibrillation cannot be performed
in BLS ambulances) E1

A0394 ALS specialized service disposable supplies; IV drug therapy

E1
A0396 ALS specialized service disposable supplies; esophageal intubation
E1

A0398 ALS routine disposable supplies E1

A0420 Ambulance waiting time (ALS or BLS), one half (½) hour
increments E1

Waiting Time Table

UNITS TIME
1 ½ to 1 hr.
2 1 to 1½ hrs.
3 1½ to 2 hrs.
4 2 to 2½ hrs.
5 2½ to 3 hrs.
6 3 to 3½ hrs.
7 3½ to 4 hrs.
8 4 to 4½ hrs.
9 4½ to 5 hrs.
10 5 to 5½ hrs.

A0422 Ambulance (ALS or BLS) oxygen and oxygen supplies, life

sustaining situation E1

A0424 Extra ambulance attendant, ground (ALS or BLS) or air (fixed or

rotary winged); (requires medical review) E1

✽ A0425 Ground mileage, per statute mile A

✽ A0426 Ambulance service, advanced life support, non-emergency

transport, Level 1 (ALS 1) A

✽ A0427 Ambulance service, advanced life support, emergency transport,

Level 1 (ALS 1-Emergency) A

✽ A0428 Ambulance service, basic life support, non-emergency transport

(BLS) A
 ✽ A0429 Ambulance service, basic life support, emergency transport (BLS-
Emergency) A

✽ A0430 Ambulance service, conventional air services, transport, one way

(fixed wing) A

✽ A0431 Ambulance service, conventional air services, transport, one way

(rotary wing) A

✽ A0432 Paramedic intercept (PI), rural area, transport furnished by a

volunteer ambulance company, which is prohibited by state law
from billing third party payers A

✽ A0433 Advanced life support, Level 2 (ALS2) A

✽ A0434 Specialty care transport (SCT) A

✽ A0435 Fixed wing air mileage, per statute mile A

✽ A0436 Rotary wing air mileage, per statute mile A

A0888 Noncovered ambulance mileage, per mile (e.g., for miles traveled
beyond closest appropriate facility) E1

MCM: 2125
A0998 Ambulance response and treatment, no transport E1

IOM: 100-02, 10, 20

❂ A0999 Unlisted ambulance service A

IOM: 100-02, 10, 20

MEDICAL AND SURGICAL SUPPLIES (A2001-A8004)

Wound Supplies
A2001 Innovamatrix ac, per square centimeter N1

A2002 Mirragen advanced wound matrix, per square centimeter N1

A2003 Bio-connekt wound matrix, per square centimeter N1

A2004 Xcellistem, 1 mg N1

A2005 Microlyte matrix, per square centimeter N1

A2006 Novosorb synpath dermal matrix, per square centimeter N1

A2007 Restrata, per square centimeter N1

A2008 Theragenesis, per square centimeter N1

A2009 Symphony, per square centimeter N1

A2010 Apis, per square centimeter N1

▶ A2014 Omeza collagen matrix, per 100 mg N1

 ▶ A2015 Phoenix wound matrix, per square centimeter N1

▶ A2016 Permeaderm B, per square centimeter N1

▶ A2017 Permeaderm glove, each N1

▶ A2018 Permeaderm C, per square centimeter N1

Injection and Infusion

✽ A4206 Syringe with needle, sterile 1 cc or less, each N

✽ A4207 Syringe with needle, sterile 2 cc, each N

✽ A4208 Syringe with needle, sterile 3 cc, each N

✽ A4209 Syringe with needle, sterile 5 cc or greater, each N

A4210 Needle-free injection device, each E1

IOM: 100-03, 4, 280.1

❂ A4211 Supplies for self-administered injections N

IOM: 100-02, 15, 50

✽ A4212 Non-coring needle or stylet with or without catheter N

✽ A4213 Syringe, sterile, 20 cc or greater, each N

✽ A4215 Needle, sterile, any size, each N

❂ A4216 Sterile water, saline and/or dextrose diluent/flush, 10 ml N

Other: Sodium Chloride, Bacteriostatic, Syrex

IOM: 100-02, 15, 50
❂ A4217 Sterile water/saline, 500 ml N

Other: Sodium Chloride

IOM: 100-02, 15, 50
❂ A4218 Sterile saline or water, metered dose dispenser, 10 ml N

Other: Sodium Chloride

❂ A4220 Refill kit for implantable infusion pump N

Do not report with 95990 or 95991 since Medicare payment for

these codes includes the refill kit.
IOM: 100-03, 4, 280.1
✽ A4221 Supplies for maintenance of noninsulin drug infusion catheter, per
week (list drugs separately) N

Includes dressings for catheter site and flush solutions not directly
related to drug infusion.
 ✽ A4222 Infusion supplies for external drug infusion pump, per cassette or
bag (list drug separately) N

Includes cassette or bag, diluting solutions, tubing and/or

administration supplies, port cap changes, compounding charges,
and preparation charges.
✽ A4223 Infusion supplies not used with external infusion pump, per cassette
or bag (list drugs separately) N

IOM: 100-03, 4, 280.1

Figure 1 Insulin pump.

✽ A4224 Supplies for maintenance of insulin infusion catheter, per week

N

❂ A4225 Supplies for external insulin infusion pump, syringe type cartridge,
sterile, each N

IOM: 100-03, 1, 50.3

✽ A4226 Supplies for maintenance of insulin infusion pump with dosage rate
adjustment using therapeutic continuous glucose sensing, per week
N
❂ A4230 Infusion set for external insulin pump, non-needle cannula type
N
Requires prior authorization and copy of invoice.
IOM: 100-03, 4, 280.1
❂ A4231 Infusion set for external insulin pump, needle type N

Requires prior authorization and copy of invoice.

IOM: 100-03, 4, 280.1
A4232 Syringe with needle for external insulin pump, sterile, 3 cc
E1
Reports insulin reservoir for use with external insulin infusion
pump (E0784); may be glass or plastic; includes needle for drawing
 up insulin. Does not include insulin for use in reservoir.
IOM: 100-03, 4, 280.1

Replacement Batteries
✽ A4233 Replacement battery, alkaline (other than J cell), for use with
medically necessary home blood glucose monitor owned by patient,
each E1

✽ A4234 Replacement battery, alkaline, J cell, for use with medically

necessary home blood glucose monitor owned by patient, each
E1
✽ A4235 Replacement battery, lithium, for use with medically necessary
home blood glucose monitor owned by patient, each E1

✽ A4236 Replacement battery, silver oxide, for use with medically necessary
home blood glucose monitor owned by patient, each E1

Miscellaneous Supplies
▶ A4238 Supply allowance for adjunctive, non-implanted continuous glucose
monitor (cgm), includes all supplies and accessories, 1 month
supply = 1 unit of service
▶ A4239 Supply allowance for non-adjunctive, non-implanted continuous
glucose monitor (cgm), includes all supplies and accessories, 1
month supply = 1 unit of service Y

✽ A4244 Alcohol or peroxide, per pint N

✽ A4245 Alcohol wipes, per box N

✽ A4246 Betadine or Phisohex solution, per pint N

✽ A4247 Betadine or iodine swabs/wipes, per box N

✽ A4248 Chlorhexidine containing antiseptic, 1 ml N

A4250 Urine test or reagent strips or tablets (100 tablets or strips)

E1
IOM: 100-02, 15, 110
A4252 Blood ketone test or reagent strip, each E1

Medicare Statute 1861(n)

❂ A4253 Blood glucose test or reagent strips for home blood glucose monitor,
per 50 strips N

Test strips (1 unit = 50 strips); noninsulin treated (every 3 months)

100 test strips (1×/day testing), 100 lancets (1×/day testing);
modifier KS
 IOM: 100-03, 1, 40.2
❂ A4255 Platforms for home blood glucose monitor, 50 per box
N
IOM: 100-03, 1, 40.2
❂ A4256 Normal, low and high calibrator solution/chips N

IOM: 100-03, 1, 40.2

✽ A4257 Replacement lens shield cartridge for use with laser skin piercing
device, each E1

❂ A4258 Spring-powered device for lancet, each N

IOM: 100-03, 1, 40.2

❂ A4259 Lancets, per box of 100 N

IOM: 100-03, 1, 40.2

A4261 Cervical cap for contraceptive use ♀ E1

Medicare Statute 1862A1

❂ A4262 Temporary, absorbable lacrimal duct implant, each N

IOM: 100-04, 12, 20.3, 30.4

❂ A4263 Permanent, long term, non-dissolvable lacrimal duct implant, each
N

Bundled with insertion if performed in physician office.

IOM: 100-04, 12, 30.4
A4264 Permanent implantable contraceptive intratubal occlusion device(s)
and delivery system ♀ E1

Reports the Essure device.

❂ A4265 Paraffin, per pound N

IOM: 100-03, 4, 280.1

A4266 Diaphragm for contraceptive use ♀ E1

A4267 Contraceptive supply, condom, male, each ♂ E1

A4268 Contraceptive supply, condom, female, each ♀ E1

A4269 Contraceptive supply, spermicide (e.g., foam, gel), each

E1
✽ A4270 Disposable endoscope sheath, each N

✽ A4280 Adhesive skin support attachment for use with external breast
prosthesis, each ♀ N

✽ A4281 Tubing for breast pump, replacement ♀ E1

✽ A4282 Adapter for breast pump, replacement ♀ E1

 ✽ A4283 Cap for breast pump bottle, replacement ♀ E1

✽ A4284 Breast shield and splash protector for use with breast pump,
replacement ♀ E1

✽ A4285 Polycarbonate bottle for use with breast pump, replacement ♀ E1

✽ A4286 Locking ring for breast pump, replacement ♀ E1

✽ A4290 Sacral nerve stimulation test lead, each N

Service not separately priced by Part B (e.g., services not covered,

bundled, used by Part A only)

Implantable Catheters
❂ A4300 Implantable access catheter, (e.g., venous, arterial, epidural
subarachnoid, or peritoneal, etc.) external access N

IOM: 100-02, 15, 120

✽ A4301 Implantable access total; catheter, port/reservoir (e.g., venous,
arterial, epidural, subarachnoid, peritoneal, etc.) N

Disposable Drug Delivery System

✽ A4305 Disposable drug delivery system, flow rate of 50 ml or greater per
hour N

✽ A4306 Disposable drug delivery system, flow rate of less than 50 ml per
hour N

Incontinence Appliances and Care Supplies

❂ A4310 Insertion tray without drainage bag and without catheter
(accessories only) N

IOM: 100-02, 15, 120

❂ A4311 Insertion tray without drainage bag with indwelling catheter, Foley
type, two-way latex with coating (Teflon, silicone, silicone
elastomer, or hydrophilic, etc.) N

IOM: 100-02, 15, 120

❂ A4312 Insertion tray without drainage bag with indwelling catheter, Foley
type, two-way, all silicone N

Must meet criteria for indwelling catheter and medical record must
justify need for:
• Recurrent encrustation
 • Inability to pass a straight catheter
• Sensitivity to latex
Must be medically necessary.
IOM: 100-02, 15, 120
❂ A4313 Insertion tray without drainage bag with indwelling catheter, Foley
type, three-way, for continuous irrigation N

Must meet criteria for indwelling catheter and medical record must
justify need for:
• Recurrent encrustation
• Inability to pass a straight catheter
• Sensitivity to latex
Must be medically necessary.
IOM: 100-02, 15, 120

Figure 2 Foley catheter.

❂ A4314 Insertion tray with drainage bag with indwelling catheter, Foley
type, two-way latex with coating (Teflon, silicone, silicone
elastomer or hydrophilic, etc.) N

IOM: 100-02, 15, 120

❂ A4315 Insertion tray with drainage bag with indwelling catheter, Foley
type, two-way, all silicone N

IOM: 100-02, 15, 120

❂ A4316 Insertion tray with drainage bag with indwelling catheter, Foley
type, three-way, for continuous irrigation N

IOM: 100-02, 15, 120

❂ A4320 Irrigation tray with bulb or piston syringe, any purpose
N
IOM: 100-02, 15, 120
❂ A4321 Therapeutic agent for urinary catheter irrigation N

IOM: 100-02, 15, 120

❂ A4322 Irrigation syringe, bulb, or piston, each N

IOM: 100-02, 15, 120

❂ A4326 Male external catheter with integral collection chamber, any type,
each ♂ N

IOM: 100-02, 15, 120

❂ A4327 Female external urinary collection device; meatal cup, each
♀ N

IOM: 100-02, 15, 120

❂ A4328 Female external urinary collection device; pouch, each ♀
N
IOM: 100-02, 15, 120
❂ A4330 Perianal fecal collection pouch with adhesive, each N

IOM: 100-02, 15, 120

❂ A4331 Extension drainage tubing, any type, any length, with
connector/adaptor, for use with urinary leg bag or urostomy pouch,
each N

IOM: 100-02, 15, 120

❂ A4332 Lubricant, individual sterile packet, each N

IOM: 100-02, 15, 120

❂ A4333 Urinary catheter anchoring device, adhesive skin attachment, each
N

IOM: 100-02, 15, 120

❂ A4334 Urinary catheter anchoring device, leg strap, each N

IOM: 100-02, 15, 120

❂ A4335 Incontinence supply; miscellaneous N
 IOM: 100-02, 15, 120
❂ A4336 Incontinence supply, urethral insert, any type, each N

IOM: 100-02, 15, 120

❂ A4337 Incontinence supply, rectal insert, any type, each N

IOM: 100-02, 15, 120

❂ A4338 Indwelling catheter; Foley type, two-way latex with coating (Teflon,
silicone, silicone elastomer, or hydrophilic, etc.), each
N
IOM: 100-02, 15, 120
❂ A4340 Indwelling catheter; specialty type (e.g., coude, mushroom, wing,
etc.), each N

Must meet criteria for indwelling catheter and medical record must
justify need for:
• Recurrent encrustation
• Inability to pass a straight catheter
• Sensitivity to latex
Must be medically necessary.
IOM: 100-02, 15, 120
❂ A4344 Indwelling catheter, Foley type, two-way, all silicone, each
N

Must meet criteria for indwelling catheter and medical record must
justify need for:
• Recurrent encrustation
• Inability to pass a straight catheter
• Sensitivity to latex
Must be medically necessary.
IOM: 100-02, 15, 120
❂ A4346 Indwelling catheter; Foley type, three way for continuous irrigation,
each N

IOM: 100-02, 15, 120

❂ A4349 Male external catheter, with or without adhesive, disposable, each
♂ N

IOM: 100-02, 15, 120

❂ A4351 Intermittent urinary catheter; straight tip, with or without coating
(Teflon, silicone, silicone elastomer, or hydrophilic, etc.), each
N

IOM: 100-02, 15, 120

 ❂ A4352 Intermittent urinary catheter; coude (curved) tip, with or without
coating (Teflon, silicone, silicone elastomeric, or hydrophilic, etc.),
each N

IOM: 100-02, 15, 120

❂ A4353 Intermittent urinary catheter, with insertion supplies N

IOM: 100-02, 15, 120

❂ A4354 Insertion tray with drainage bag but without catheter
N
IOM: 100-02, 15, 120
❂ A4355 Irrigation tubing set for continuous bladder irrigation through a
three-way indwelling Foley catheter, each N

IOM: 100-02, 15, 120

External Urinary Supplies

❂ A4356 External urethral clamp or compression device (not to be used for
catheter clamp), each N

IOM: 100-02, 15, 120

❂ A4357 Bedside drainage bag, day or night, with or without anti-reflux
device, with or without tube, each N

IOM: 100-02, 15, 120

Figure 3 Ostomy pouch.

❂ A4358 Urinary drainage bag, leg or abdomen, vinyl, with or without tube,
with straps, each N

IOM: 100-02, 15, 120

❂ A4360 Disposable external urethral clamp or compression device, with pad
and/or pouch, each N
Ostomy Supplies
❂ A4361 Ostomy faceplate, each N

IOM: 100-02, 15, 120

❂ A4362 Skin barrier; solid, 4 × 4 or equivalent; each N

IOM: 100-02, 15, 120

❂ A4363 Ostomy clamp, any type, replacement only, each E1

❂ A4364 Adhesive, liquid or equal, any type, per oz N

Fee schedule category: Ostomy, tracheostomy, and urologicals

items.
IOM: 100-02, 15, 120
✽ A4366 Ostomy vent, any type, each N

❂ A4367 Ostomy belt, each N

IOM: 100-02, 15, 120

✽ A4368 Ostomy filter, any type, each N

❂ A4369 Ostomy skin barrier, liquid (spray, brush, etc.), per oz N

IOM: 100-02, 15, 120

❂ A4371 Ostomy skin barrier, powder, per oz N

IOM: 100-02, 15, 120

❂ A4372 Ostomy skin barrier, solid 4 × 4 or equivalent, standard wear, with
built-in convexity, each N

IOM: 100-02, 15, 120

❂ A4373 Ostomy skin barrier, with flange (solid, flexible, or accordion), with
built-in convexity, any size, each N

IOM: 100-02, 15, 120

❂ A4375 Ostomy pouch, drainable, with faceplate attached, plastic, each
N

IOM: 100-02, 15, 120

❂ A4376 Ostomy pouch, drainable, with faceplate attached, rubber, each
N

IOM: 100-02, 15, 120

❂ A4377 Ostomy pouch, drainable, for use on faceplate, plastic, each
N

IOM: 100-02, 15, 120

❂ A4378 Ostomy pouch, drainable, for use on faceplate, rubber, each
N
 IOM: 100-02, 15, 120
❂ A4379 Ostomy pouch, urinary, with faceplate attached, plastic, each
N

IOM: 100-02, 15, 120

❂ A4380 Ostomy pouch, urinary, with faceplate attached, rubber, each
N

IOM: 100-02, 15, 120

❂ A4381 Ostomy pouch, urinary, for use on faceplate, plastic, each
N

IOM: 100-02, 15, 120

❂ A4382 Ostomy pouch, urinary, for use on faceplate, heavy plastic, each
N

IOM: 100-02, 15, 120

❂ A4383 Ostomy pouch, urinary, for use on faceplate, rubber, each
N
IOM: 100-02, 15, 120
❂ A4384 Ostomy faceplate equivalent, silicone ring, each N

IOM: 100-02, 15, 120

❂ A4385 Ostomy skin barrier, solid 4 × 4 or equivalent, extended wear,
without built-in convexity, each N

IOM: 100-02, 15, 120

❂ A4387 Ostomy pouch closed, with barrier attached, with built-in convexity
(1 piece), each N

IOM: 100-02, 15, 120

❂ A4388 Ostomy pouch, drainable, with extended wear barrier attached (1
piece), each N

IOM: 100-02, 15, 120

❂ A4389 Ostomy pouch, drainable, with barrier attached, with built-in
convexity (1 piece), each N

IOM: 100-02, 15, 120

❂ A4390 Ostomy pouch, drainable, with extended wear barrier attached, with
built-in convexity (1 piece), each N

IOM: 100-02, 15, 120

❂ A4391 Ostomy pouch, urinary, with extended wear barrier attached (1
piece), each N

IOM: 100-02, 15, 120

❂ A4392 Ostomy pouch, urinary, with standard wear barrier attached, with
built-in convexity (1 piece), each N

IOM: 100-02, 15, 120

❂ A4393 Ostomy pouch, urinary, with extended wear barrier attached, with
built-in convexity (1 piece), each N

IOM: 100-02, 15, 120

❂ A4394 Ostomy deodorant, with or without lubricant, for use in ostomy
pouch, per fluid ounce N

IOM: 100-02, 15, 20

❂ A4395 Ostomy deodorant for use in ostomy pouch, solid, per tablet
N
IOM: 100-02, 15, 20
❂ A4396 Ostomy belt with peristomal hernia support N

IOM: 100-02, 15, 120

❂ A4398 Ostomy irrigation supply; bag, each N

IOM: 100-02, 15, 120

❂ A4399 Ostomy irrigation supply; cone/catheter, with or without brush
N

IOM: 100-02, 15, 120

❂ A4400 Ostomy irrigation set N

IOM: 100-02, 15, 120

❂ A4402 Lubricant, per ounce N

IOM: 100-02, 15, 120

❂ A4404 Ostomy ring, each N

IOM: 100-02, 15, 120

❂ A4405 Ostomy skin barrier, non-pectin based, paste, per ounce N

IOM: 100-02, 15, 120

❂ A4406 Ostomy skin barrier, pectin-based, paste, per ounce N

IOM: 100-02, 15, 120

❂ A4407 Ostomy skin barrier, with flange (solid, flexible, or accordion),
extended wear, with built-in convexity, 4 × 4 inches or smaller, each
N

IOM: 100-02, 15, 120

❂ A4408 Ostomy skin barrier, with flange (solid, flexible, or accordion),
extended wear, with built-in convexity, larger than 4 × 4 inches,
each N

IOM: 100-02, 15, 120

❂ A4409 Ostomy skin barrier, with flange (solid, flexible, or accordion),
extended wear, without built-in convexity, 4 × 4 inches or smaller,
each N

IOM: 100-02, 15, 120

❂ A4410 Ostomy skin barrier, with flange (solid, flexible, or accordion),
extended wear, without built-in convexity, larger than 4 × 4 inches,
each N

IOM: 100-02, 15, 120

❂ A4411 Ostomy skin barrier, solid 4 × 4 or equivalent, extended wear, with
built-in convexity, each N

❂ A4412 Ostomy pouch, drainable, high output, for use on a barrier with
flange (2 piece system), without filter, each N

IOM: 100-02, 15, 120

❂ A4413 Ostomy pouch, drainable, high output, for use on a barrier with
flange (2 piece system), with filter, each N

IOM: 100-02, 15, 120

❂ A4414 Ostomy skin barrier, with flange (solid, flexible, or accordion),
without built-in convexity, 4 × 4 inches or smaller, each
N
IOM: 100-02, 15, 120
❂ A4415 Ostomy skin barrier, with flange (solid, flexible, or accordion),
without built-in convexity, larger than 4 × 4 inches, each
N
IOM: 100-02, 15, 120
✽ A4416 Ostomy pouch, closed, with barrier attached, with filter (1 piece),
each N

✽ A4417 Ostomy pouch, closed, with barrier attached, with built-in

convexity, with filter (1 piece), each N

✽ A4418 Ostomy pouch, closed; without barrier attached, with filter (1 piece),
each N

✽ A4419 Ostomy pouch, closed; for use on barrier with non-locking flange,
with filter (2 piece), each N

✽ A4420 Ostomy pouch, closed; for use on barrier with locking flange (2
piece), each N

✽ A4421 Ostomy supply; miscellaneous N

❂ A4422 Ostomy absorbent material (sheet/pad/crystal packet) for use in

ostomy pouch to thicken liquid stomal output, each N

IOM: 100-02, 15, 120

 ✽ A4423 Ostomy pouch, closed; for use on barrier with locking flange, with
filter (2 piece), each N

✽ A4424 Ostomy pouch, drainable, with barrier attached, with filter (1 piece),
each N

✽ A4425 Ostomy pouch, drainable; for use on barrier with non-locking

flange, with filter (2 piece system), each N

✽ A4426 Ostomy pouch, drainable; for use on barrier with locking flange (2
piece system), each N

✽ A4427 Ostomy pouch, drainable; for use on barrier with locking flange,
with filter (2 piece system), each N

✽ A4428 Ostomy pouch, urinary, with extended wear barrier attached, with
faucet-type tap with valve (1 piece), each N

✽ A4429 Ostomy pouch, urinary, with barrier attached, with built-in

convexity, with faucet-type tap with valve (1 piece), each
N
✽ A4430 Ostomy pouch, urinary, with extended wear barrier attached, with
built-in convexity, with faucet-type tap with valve (1 piece), each
N

✽ A4431 Ostomy pouch, urinary; with barrier attached, with faucet-type tap
with valve (1 piece), each N

✽ A4432 Ostomy pouch, urinary; for use on barrier with non-locking flange,
with faucet-type tap with valve (2 piece), each N

✽ A4433 Ostomy pouch, urinary; for use on barrier with locking flange (2
piece), each N

✽ A4434 Ostomy pouch, urinary; for use on barrier with locking flange, with
faucet-type tap with valve (2 piece), each N

✽ A4435 Ostomy pouch, drainable, high output, with extended wear barrier
(one-piece system), with or without filter, each N

✽ A4436 Irrigation supply; sleeve, reusable, per month N

✽ A4437 Irrigation supply; sleeve, disposable, per month N

Miscellaneous Supplies
❂ A4450 Tape, non-waterproof, per 18 square inches N

If used with surgical dressings, billed with AW modifier (in addition

to appropriate A1-A9 modifier).
IOM: 100-02, 15, 120
❂ A4452 Tape, waterproof, per 18 square inches N
 If used with surgical dressings, billed with AW modifier (in addition
to appropriate A1-A9 modifier).
IOM: 100-02, 15, 120
❂ A4453 Rectal catheter for use with the manual pump-operated enema
system, replacement only N

If used with surgical dressings, billed with AW modifier (in addition

to appropriate A1-A9 modifier).
❂ A4455 Adhesive remover or solvent (for tape, cement or other adhesive),
per ounce N

IOM: 100-02, 15, 120

❂ A4456 Adhesive remover, wipes, any type, each N

May be reimbursed for male or female clients to home health DME

providers and DME medical suppliers in the home setting.
IOM: 100-02, 15, 120
✽ A4458 Enema bag with tubing, reusable N

✽ A4459 Manual pump-operated enema system, includes balloon, catheter

and all accessories, reusable, any type N

✽ A4461 Surgical dressing holder, non-reusable, each N

✽ A4463 Surgical dressing holder, reusable, each N

✽ A4465 Non-elastic binder for extremity N

A4467 Belt, strap, sleeve, garment, or covering, any type E1

❂ A4470 Gravlee jet washer N

Symptoms suggestive of endometrial disease must be present for

this disposable diagnostic tool to be covered.
IOM: 100-02, 16, 90; 100-03, 4, 230.5
❂ A4480 VABRA aspirator N

Symptoms suggestive of endometrial disease must be present for

this disposable diagnostic tool to be covered.
IOM: 100-02, 16, 90; 100-03, 4, 230.6
❂ A4481 Tracheostoma filter, any type, any size, each N

IOM: 100-02, 15, 120

❂ A4483 Moisture exchanger, disposable, for use with invasive mechanical
ventilation N

IOM: 100-02, 15, 120

A4490 Surgical stockings above knee length, each E1
 IOM: 100-02, 15, 100; 100-02, 15, 110; 100-03, 4, 280.1
A4495 Surgical stockings thigh length, each E1

IOM: 100-02, 15, 100; 100-02, 15, 110; 100-03, 4, 280.1

A4500 Surgical stockings below knee length, each E1

IOM: 100-02, 15, 100; 100-02, 15, 110; 100-03, 4, 280.1

A4510 Surgical stockings full length, each E1

IOM: 100-02, 15, 100; 100-02, 15, 110; 100-03, 4, 280.1

A4520 Incontinence garment, any type (e.g., brief, diaper), each
E1
IOM: 100-03, 4, 280.1
❂ A4550 Surgical trays B

No longer payable by Medicare; included in practice expense for

procedures. Some private payers may pay, most private payers
follow Medicare guidelines.
IOM: 100-04, 12, 20.3, 30.4
A4553 Non-disposable underpads, all sizes E1

IOM: 100-03, 4, 280.1

A4554 Disposable underpads, all sizes E1

IOM: 100-03, 4, 280.1

A4555 Electrode/transducer for use with electrical stimulation device used
for cancer treatment, replacement only E1

✽ A4556 Electrodes (e.g., apnea monitor), per pair N

✽ A4557 Lead wires (e.g., apnea monitor), per pair N

✽ A4558 Conductive gel or paste, for use with electrical device (e.g., TENS,
NMES), per oz N

✽ A4559 Coupling gel or paste, for use with ultrasound device, per oz
N
✽ A4561 Pessary, rubber, any type ♀ N

✽ A4562 Pessary, non-rubber, any type ♀ N

✽ A4563 Rectal control system for vaginal insertion, for long term use,
includes pump and all supplies and accessories, any type each N

✽ A4565 Slings N

A4566 Shoulder sling or vest design, abduction restrainer, with or without

swathe control, prefabricated, includes fitting and adjustment
E1
 A4570 Splint E1

IOM: 100-02, 6, 10; 100-02, 15, 100; 100-04, 4, 240

✽ A4575 Topical hyperbaric oxygen chamber, disposable A

A4580 Cast supplies (e.g., plaster) E1

IOM: 100-02, 6, 10; 100-02, 15, 100; 100-04, 4, 240

A4590 Special casting material (e.g., fiberglass) E1

IOM: 100-02, 6, 10; 100-02, 15, 100; 100-04, 4, 240

❂ A4595 Electrical stimulator supplies, 2 lead, per month (e.g., TENS,
NMES) N

IOM: 100-03, 2, 160.13

▶ A4596 Cranial electrotherapy stimulation (CES) system supplies and
accessories, per month
✽ A4600 Sleeve for intermittent limb compression device, replacement only,
each E1

Figure 4 Arm sling.

✽ A4601 Lithium ion battery, rechargeable, for non-prosthetic use,

replacement E1

✽ A4602 Replacement battery for external infusion pump owned by patient,

lithium, 1.5 volt, each N

✽ A4604 Tubing with integrated heating element for use with positive airway
pressure device N

✽ A4605 Tracheal suction catheter, closed system, each N

✽ A4606 Oxygen probe for use with oximeter device, replacement

 N
✽ A4608 Transtracheal oxygen catheter, each N

Supplies for Respiratory and Oxygen Equipment

A4611 Battery, heavy duty; replacement for patient owned ventilator
E1
Medicare Statute 1834(a)(3)(a)
A4612 Battery cables; replacement for patient-owned ventilator E1

Medicare Statute 1834(a)(3)(a)

A4613 Battery charger; replacement for patient-owned ventilator E1

Medicare Statute 1834(a)(3)(a)

✽ A4614 Peak expiratory flow rate meter, hand held N

❂ A4615 Cannula, nasal N

IOM: 100-03, 2, 160.6; 100-04, 20, 100.2

❂ A4616 Tubing (oxygen), per foot N

IOM: 100-03, 2, 160.6; 100-04, 20, 100.2

Figure 5 Nasal cannula.

❂ A4617 Mouth piece N

IOM: 100-03, 2, 160.6; 100-04, 20, 100.2

❂ A4618 Breathing circuits N
 IOM: 100-03, 2, 160.6; 100-04, 20, 100.2
❂ A4619 Face tent N

IOM: 100-03, 2, 160.6; 100-04, 20, 100.2

❂ A4620 Variable concentration mask N

IOM: 100-03, 2, 160.6; 100-04, 20, 100.2

❂ A4623 Tracheostomy, inner cannula N

IOM: 100-02, 15, 120; 100-03, 1, 20.9

✽ A4624 Tracheal suction catheter, any type, other than closed system, each
N

Sterile suction catheters are medically necessary only for

tracheostomy suctioning. Limitations include three suction catheters
per day when covered for medically necessary tracheostomy
suctioning. Assign DX V44.0 or V55.0 on the claim form. (CMS
Manual System, Pub. 100-3, NCD manual, Chapter 1, Section 280-1)
❂ A4625 Tracheostomy care kit for new tracheostomy N

Dressings used with tracheostomies are included in the allowance for

the code. This starter kit is covered after a surgical tracheostomy.
(https://med.noridianmedicare.com/web/jddme/dmepos/tracheostomy-
supplies)
IOM: 100-02, 15, 120
❂ A4626 Tracheostomy cleaning brush, each N

IOM: 100-02, 15, 120

A4627 Spacer, bag, or reservoir, with or without mask, for use with metered
dose inhaler E1

IOM: 100-02, 15, 110

Figure 6 Tracheostomy cannula.

 ✽ A4628 Oropharyngeal suction catheter, each N

No more than three catheters per week are covered for medically
necessary oropharyngeal suctioning because the catheters can be
reused if cleansed and disinfected. (MS Manual System, Pub. 100-3,
NCD manual, Chapter 1, Section 280-1)
❂ A4629 Tracheostomy care kit for established tracheostomy N

IOM: 100-02, 15, 120

Replacement Parts
❂ A4630 Replacement batteries, medically necessary, transcutaneous
electrical stimulator, owned by patient E1

IOM: 100-03, 3, 160.7

✽ A4633 Replacement bulb/lamp for ultraviolet light therapy system, each
E1

✽ A4634 Replacement bulb for therapeutic light box, tabletop model N

❂ A4635 Underarm pad, crutch, replacement, each E1

IOM: 100-03, 4, 280.1

❂ A4636 Replacement, handgrip, cane, crutch, or walker, each E1

IOM: 100-03, 4, 280.1

❂ A4637 Replacement, tip, cane, crutch, walker, each E1

IOM: 100-03, 4, 280.1

✽ A4638 Replacement battery for patient-owned ear pulse generator, each
E1

✽ A4639 Replacement pad for infrared heating pad system, each E1

❂ A4640 Replacement pad for use with medically necessary alternating

pressure pad owned by patient E1

IOM: 100-03, 4, 280.1; 100-08, 5, 5.2.3

Supplies for Radiological Procedures

✽ A4641 Radiopharmaceutical, diagnostic, not otherwise classified N

Is not an applicable tracer for PET scans

✽ A4642 Indium In-111 satumomab pendetide, diagnostic, per study dose, up
to 6 millicuries N

Miscellaneous Supplies
 ✽ A4648 Tissue marker, implantable, any type, each N
Coding Clinic: 2018, Q2, P4,5; 2013, Q3, P9
✽ A4649 Surgical supply miscellaneous N

✽ A4650 Implantable radiation dosimeter, each N

❂ A4651 Calibrated microcapillary tube, each N

IOM: 100-04, 3, 40.3

❂ A4652 Microcapillary tube sealant N

IOM: 100-04, 3, 40.3

Supplies for Dialysis

✽ A4653 Peritoneal dialysis catheter anchoring device, belt, each N

❂ A4657 Syringe, with or without needle, each N

IOM: 100-04, 8, 90.3.2

❂ A4660 Sphygmomanometer/blood pressure apparatus with cuff and
stethoscope N

IOM: 100-04, 8, 90.3.2

❂ A4663 Blood pressure cuff only N

IOM: 100-04, 8, 90.3.2

A4670 Automatic blood pressure monitor E1

IOM: 100-04, 8, 90.3.2

❂ A4671 Disposable cycler set used with cycler dialysis machine, each
B
IOM: 100-04, 8, 90.3.2
❂ A4672 Drainage extension line, sterile, for dialysis, each B

IOM: 100-04, 8, 90.3.2

❂ A4673 Extension line with easy lock connectors, used with dialysis
B
IOM: 100-04, 8, 90.3.2
❂ A4674 Chemicals/antiseptics solution used to clean/sterilize dialysis
equipment, per 8 oz B

IOM: 100-04, 8, 90.3.2

❂ A4680 Activated carbon filters for hemodialysis, each N

IOM: 100-04, 8, 90.3.2

❂ A4690 Dialyzers (artificial kidneys), all types, all sizes, for hemodialysis,
each N
 IOM: 100-04, 8, 90.3.2
❂ A4706 Bicarbonate concentrate, solution, for hemodialysis, per gallon
N
IOM: 100-04, 8, 90.3.2
❂ A4707 Bicarbonate concentrate, powder, for hemodialysis, per packet
N
IOM: 100-04, 8, 90.3.2
❂ A4708 Acetate concentrate solution, for hemodialysis, per gallon
N
IOM: 100-04, 8, 90.3.2
❂ A4709 Acid concentrate, solution, for hemodialysis, per gallon N

IOM: 100-04, 8, 90.3.2

❂ A4714 Treated water (deionized, distilled, or reverse osmosis) for
peritoneal dialysis, per gallon N

IOM: 100-03, 4, 230.7; 100-04, 3, 40.3

❂ A4719 “Y set” tubing for peritoneal dialysis N

IOM: 100-04, 8, 90.3.2

❂ A4720 Dialysate solution, any concentration of dextrose, fluid volume
greater than 249 cc, but less than or equal to 999 cc, for peritoneal
dialysis N

Do not use AX modifier.

IOM: 100-04, 8, 90.3.2
❂ A4721 Dialysate solution, any concentration of dextrose, fluid volume
greater than 999 cc but less than or equal to 1999 cc, for peritoneal
dialysis N

IOM: 100-04, 8, 90.3.2

❂ A4722 Dialysate solution, any concentration of dextrose, fluid volume
greater than 1999 cc but less than or equal to 2999 cc, for peritoneal
dialysis N

IOM: 100-04, 8, 90.3.2

❂ A4723 Dialysate solution, any concentration of dextrose, fluid volume
greater than 2999 cc but less than or equal to 3999 cc, for peritoneal
dialysis N

IOM: 100-04, 8, 90.3.2

❂ A4724 Dialysate solution, any concentration of dextrose, fluid volume
greater than 3999 cc but less than or equal to 4999 cc for peritoneal
dialysis N

IOM: 100-04, 8, 90.3.2

❂ A4725 Dialysate solution, any concentration of dextrose, fluid volume
greater than 4999 cc but less than or equal to 5999 cc, for peritoneal
dialysis N

IOM: 100-04, 8, 90.3.2

❂ A4726 Dialysate solution, any concentration of dextrose, fluid volume
greater than 5999 cc, for peritoneal dialysis N

IOM: 100-04, 8, 90.3.2

✽ A4728 Dialysate solution, non-dextrose containing, 500 ml B

❂ A4730 Fistula cannulation set for hemodialysis, each N

IOM: 100-04, 8, 90.3.2

❂ A4736 Topical anesthetic, for dialysis, per gram N

IOM: 100-04, 8, 90.3.2

❂ A4737 Injectable anesthetic, for dialysis, per 10 ml N

IOM: 100-04, 8, 90.3.2

❂ A4740 Shunt accessory, for hemodialysis, any type, each N

IOM: 100-04, 8, 90.3.2

❂ A4750 Blood tubing, arterial or venous, for hemodialysis, each N

IOM: 100-04, 8, 90.3.2

❂ A4755 Blood tubing, arterial and venous combined, for hemodialysis, each
N

IOM: 100-04, 8, 90.3.2

❂ A4760 Dialysate solution test kit, for peritoneal dialysis, any type, each
N

IOM: 100-04, 8, 90.3.2

❂ A4765 Dialysate concentrate, powder, additive for peritoneal dialysis, per
packet N

IOM: 100-04, 8, 90.3.2

❂ A4766 Dialysate concentrate, solution, additive for peritoneal dialysis, per
10 ml N

IOM: 100-04, 8, 90.3.2

❂ A4770 Blood collection tube, vacuum, for dialysis, per 50 N

IOM: 100-04, 8, 90.3.2

❂ A4771 Serum clotting time tube, for dialysis, per 50 N

IOM: 100-04, 8, 90.3.2

❂ A4772 Blood glucose test strips, for dialysis, per 50 N
 IOM: 100-04, 8, 90.3.2
❂ A4773 Occult blood test strips, for dialysis, per 50 N

IOM: 100-04, 8, 90.3.2

❂ A4774 Ammonia test strips, for dialysis, per 50 N

IOM: 100-04, 8, 90.3.2

❂ A4802 Protamine sulfate, for hemodialysis, per 50 mg N

IOM: 100-04, 8, 90.3.2

❂ A4860 Disposable catheter tips for peritoneal dialysis, per 10 N

IOM: 100-04, 8, 90.3.2

❂ A4870 Plumbing and/or electrical work for home hemodialysis equipment
N

IOM: 100-04, 8, 90.3.2

❂ A4890 Contracts, repair and maintenance, for hemodialysis equipment
N

IOM: 100-02, 15, 110.2

❂ A4911 Drain bag/bottle, for dialysis, each N

❂ A4913 Miscellaneous dialysis supplies, not otherwise specified N

Items not related to dialysis must not be billed with the

miscellaneous codes A4913 or E1699.
❂ A4918 Venous pressure clamp, for hemodialysis, each N

❂ A4927 Gloves, non-sterile, per 100 N

❂ A4928 Surgical mask, per 20 N

❂ A4929 Tourniquet for dialysis, each N

❂ A4930 Gloves, sterile, per pair N

✽ A4931 Oral thermometer, reusable, any type, each N

✽ A4932 Rectal thermometer, reusable, any type, each N

Additional Ostomy Supplies

❂ A5051 Ostomy pouch, closed; with barrier attached (1 piece), each
N

IOM: 100-02, 15, 120

❂ A5052 Ostomy pouch, closed; without barrier attached (1 piece), each
N

IOM: 100-02, 15, 120

❂ A5053 Ostomy pouch, closed; for use on faceplate, each N

IOM: 100-02, 15, 120

❂ A5054 Ostomy pouch, closed; for use on barrier with flange (2 piece), each
N

IOM: 100-02, 15, 120

❂ A5055 Stoma cap N

IOM: 100-02, 15, 120

❂ A5056 Ostomy pouch, drainable, with extended wear barrier attached, with
filter (1 piece), each N

IOM: 100-02, 15, 120

❂ A5057 Ostomy pouch, drainable, with extended wear barrier attached, with
built in convexity, with filter (1 piece), each N

IOM: 100-02, 15, 120

✽ A5061 Ostomy pouch, drainable; with barrier attached (1 piece), each
N

IOM: 100-02, 15, 120

❂ A5062 Ostomy pouch, drainable; without barrier attached (1 piece), each
N

IOM: 100-02, 15, 120

❂ A5063 Ostomy pouch, drainable; for use on barrier with flange (2 piece
system), each N

IOM: 100-02, 15, 120

❂ A5071 Ostomy pouch, urinary; with barrier attached (1 piece), each
N

IOM: 100-02, 15, 120

❂ A5072 Ostomy pouch, urinary; without barrier attached (1 piece), each
N

IOM: 100-02, 15, 120

❂ A5073 Ostomy pouch, urinary; for use on barrier with flange (2 piece),
each N

IOM: 100-02, 15, 120

❂ A5081 Stoma plug or seal, any type N

IOM: 100-02, 15, 120

❂ A5082 Continent device; catheter for continent stoma N

IOM: 100-02, 15, 120

✽ A5083 Continent device, stoma absorptive cover for continent stoma
 N

❂ A5093 Ostomy accessory; convex insert N

IOM: 100-02, 15, 120

Additional Incontinence and Ostomy Supplies

❂ A5102 Bedside drainage bottle with or without tubing, rigid or expandable,
each N

IOM: 100-02, 15, 120

❂ A5105 Urinary suspensory, with leg bag, with or without tube, each
N

IOM: 100-02, 15, 120

❂ A5112 Urinary drainage bag, leg bag, leg or abdomen, latex, with or
without tube, with straps, each N

IOM: 100-02, 15, 120

❂ A5113 Leg strap; latex, replacement only, per set E1

IOM: 100-02, 15, 120

❂ A5114 Leg strap; foam or fabric, replacement only, per set
E1
IOM: 100-02, 15, 120
❂ A5120 Skin barrier, wipes or swabs, each N

IOM: 100-02, 15, 120

❂ A5121 Skin barrier; solid, 6 × 6 or equivalent, each N

IOM: 100-02, 15, 120

❂ A5122 Skin barrier; solid, 8 × 8 or equivalent, each N

IOM: 100-02, 15, 120

❂ A5126 Adhesive or non-adhesive; disk or foam pad N

IOM: 100-02, 15, 120

❂ A5131 Appliance cleaner, incontinence and ostomy appliances, per 16 oz
N

IOM: 100-02, 15, 120

❂ A5200 Percutaneous catheter/tube anchoring device, adhesive skin
attachment N

IOM: 100-02, 15, 120

Diabetic Shoes, Fitting, and Modifications

❂ A5500 For diabetics only, fitting (including follow-up), custom preparation
 and supply of off-the-shelf depth-inlay shoe manufactured to
accommodate multi-density insert(s), per shoe Y

IOM: 100-02, 15, 140

❂ A5501 For diabetics only, fitting (including follow-up), custom preparation
and supply of shoe molded from cast(s) of patient’s foot (custom-
molded shoe), per shoe Y

The diabetic patient must have at least one of the following

conditions: peripheral neuropathy with evidence of callus formation,
pre-ulcerative calluses, previous ulceration, foot deformity, previous
amputation or poor circulation.
IOM: 100-02, 15, 140
❂ A5503 For diabetics only, modification (including fitting) of off-the-shelf
depth-inlay shoe or custom-molded shoe with roller or rigid rocker
bottom, per shoe Y

IOM: 100-02, 15, 140

❂ A5504 For diabetics only, modification (including fitting) of off-the-shelf
depth-inlay shoe or custom-molded shoe with wedge(s), per shoe
Y

IOM: 100-02, 15, 140

❂ A5505 For diabetics only, modification (including fitting) of off-the-shelf
depth-inlay shoe or custom-molded shoe with metatarsal bar, per
shoe Y

IOM: 100-02, 15, 140

❂ A5506 For diabetics only, modification (including fitting) of off-the-shelf
depth-inlay shoe or custom-molded shoe with off-set heel(s), per
shoe Y

IOM: 100-02, 15, 140

❂ A5507 For diabetics only, not otherwise specified modification (including
fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe, per
shoe Y

Only used for not otherwise specified therapeutic modifications to

shoe or for repairs to a diabetic shoe(s)
IOM: 100-02, 15, 140
❂ A5508 For diabetics only, deluxe feature of off-the-shelf depth-inlay shoe
or custom-molded shoe, per shoe Y

IOM: 100-02, 15, 40

❂ A5510 For diabetics only, direct formed, compression molded to patient’s
 foot without external heat source, multiple-density insert(s)
prefabricated, per shoe N

IOM: 100-02, 15, 140

✽ A5512 For diabetics only, multiple density insert, direct formed, molded to
foot after external heat source of 230 degrees Fahrenheit or higher,
total contact with patient’s foot, including arch, base layer minimum
of 1/4 inch material of shore a 35 durometer or 3/16 inch material of
shore a 40 durometer (or higher), prefabricated, each Y

✽ A5513 For diabetics only, multiple density insert, custom molded from
model of patient’s foot, total contact with patient’s foot, including
arch, base layer minimum of 3/16 inch material of shore a 35
durometer (or higher), includes arch filler and other shaping
material, custom fabricated, each Y

❂ A5514 For diabetics only, multiple density insert, made by direct carving
with cam technology from a rectified CAD model created from a
digitized scan of the patient, total contact with patient’s foot,
including arch, base layer minimum of 3/16 inch material of shore a
35 durometer (or higher), includes arch filler and other shaping
material, custom fabricated, each Y

Dressings
A6000 Non-contact wound warming wound cover for use with the non-
contact wound warming device and warming card E1

IOM: 100-02, 16, 20

❂ A6010 Collagen based wound filler, dry form, sterile, per gram of collagen
N

IOM: 100-02, 15, 100

❂ A6011 Collagen based wound filler, gel/paste, per gram of collagen
N
IOM: 100-02, 15, 100
❂ A6021 Collagen dressing, sterile, size 16 sq. in. or less, each N

IOM: 100-02, 15, 100

❂ A6022 Collagen dressing, sterile, size more than 16 sq. in. but less than or
equal to 48 sq. in., each N

IOM: 100-02, 15, 100

❂ A6023 Collagen dressing, sterile, size more than 48 sq. in., each N

IOM: 100-02, 15, 100

❂ A6024 Collagen dressing wound filler, sterile, per 6 inches N
 IOM: 100-02, 15, 100
✽ A6025 Gel sheet for dermal or epidermal application (e.g., silicone,
hydrogel, other), each N

If used for the treatment of keloids or other scars, a silicone gel

sheet will not meet the definition of the surgical dressing benefit and
will be denied as noncovered.
❂ A6154 Wound pouch, each N

Waterproof collection device with drainable port that adheres to skin

around wound. Usual dressing change is up to 3 times per week.
IOM: 100-02, 15, 100
❂ A6196 Alginate or other fiber gelling dressing, wound cover, sterile, pad
size 16 sq. in. or less, each dressing N

IOM: 100-02, 15, 100

❂ A6197 Alginate or other fiber gelling dressing, wound cover, sterile, pad
size more than 16 sq. in., but less than or equal to 48 sq. in., each
dressing N

IOM: 100-02, 15, 100

❂ A6198 Alginate or other fiber gelling dressing, wound cover, sterile, pad
size more than 48 sq. in., each dressing N

IOM: 100-02, 15, 100

❂ A6199 Alginate or other fiber gelling dressing, wound filler, sterile, per 6
inches N

IOM: 100-02, 15, 100

❂ A6203 Composite dressing, sterile, pad size 16 sq. in. or less, with any size
adhesive border, each dressing N

Usual composite dressing change is up to 3 times per week, one

wound cover per dressing change.
IOM: 100-02, 15, 100
❂ A6204 Composite dressing, sterile, pad size more than 16 sq. in. but less
than or equal to 48 sq. in., with any size adhesive border, each
dressing N

Usual composite dressing change is up to 3 times per week, one

wound cover per dressing change.
IOM: 100-02, 15, 100
❂ A6205 Composite dressing, sterile, pad size more than 48 sq. in., with any
size adhesive border, each dressing N

Usual composite dressing change is up to 3 times per week, one

 wound cover per dressing change.
IOM: 100-02, 15, 100
❂ A6206 Contact layer, sterile, 16 sq. in. or less, each dressing N

Contact layers are porous to allow wound fluid to pass through for
absorption by separate overlying dressing and are not intended to be
changed with each dressing change. Usual dressing change is up to
once per week.
IOM: 100-02, 15, 100
❂ A6207 Contact layer, sterile, more than 16 sq. in. but less than or equal to
48 sq. in., each dressing N

Contact layer dressings are used to line the entire wound; they are
not intended to be changed with each dressing change. Usual
dressing change is up to once per week.
IOM: 100-02, 15, 100
❂ A6208 Contact layer, sterile, more than 48 sq. in., each dressing N

Contact layer dressings are used to line the entire wound; they are
not intended to be changed with each dressing change. Usual
dressing change is up to once per week.
IOM: 100-02, 15, 100
❂ A6209 Foam dressing, wound cover, sterile, pad size 16 sq. in. or less,
without adhesive border, each dressing N

Made of open cell, medical grade expanded polymer; with

nonadherent property over wound site.
IOM: 100-02, 15, 100
❂ A6210 Foam dressing, wound cover, sterile, pad size more than 16 sq. in.
but less than or equal to 48 sq. in., without adhesive border, each
dressing N

Foam dressings are covered items when used on full thickness

wounds (e.g., stage III or IV ulcers) with moderate to heavy
exudates. Usual dressing change for a foam wound cover when used
as primary dressing is up to 3 times per week. When foam wound
cover is used as a secondary dressing for wounds with very heavy
exudates, dressing change may be up to 3 times per week. Usual
dressing change for foam wound fillers is up to once per day
(A6209-A6215).
IOM: 100-02, 15, 100
❂ A6211 Foam dressing, wound cover, sterile, pad size more than 48 sq. in.,
without adhesive border, each dressing N
 IOM: 100-02, 15, 100
❂ A6212 Foam dressing, wound cover, sterile, pad size 16 sq. in. or less, with
any size adhesive border, each dressing N

IOM: 100-02, 15, 100

❂ A6213 Foam dressing, wound cover, sterile, pad size more than 16 sq. in.
but less than or equal to 48 sq. in., with any size adhesive border,
each dressing N

IOM: 100-02, 15, 100

❂ A6214 Foam dressing, wound cover, sterile, pad size more than 48 sq. in.,
with any size adhesive border, each dressing N

IOM: 100-02, 15, 100

❂ A6215 Foam dressing, wound filler, sterile, per gram N

IOM: 100-02, 15, 100

❂ A6216 Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less,
without adhesive border, each dressing N

IOM: 100-02, 15, 100

❂ A6217 Gauze, non-impregnated, non-sterile, pad size more than 16 sq. in.
but less than or equal to 48 sq. in., without adhesive border, each
dressing N

IOM: 100-02, 15, 100

❂ A6218 Gauze, non-impregnated, non-sterile, pad size more than 48 sq. in.,
without adhesive border, each dressing N

IOM: 100-02, 15, 100

❂ A6219 Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, with any
size adhesive border, each dressing N

IOM: 100-02, 15, 100

❂ A6220 Gauze, non-impregnated, sterile, pad size more than 16 sq. in. but
less than or equal to 48 sq. in., with any size adhesive border, each
dressing N

IOM: 100-02, 15, 100

❂ A6221 Gauze, non-impregnated, sterile, pad size more than 48 sq. in., with
any size adhesive border, each dressing N

IOM: 100-02, 15, 100

❂ A6222 Gauze, impregnated with other than water, normal saline, or
hydrogel, sterile, pad size 16 sq. in. or less, without adhesive border,
each dressing N

Substances may have been incorporated into dressing material (i.e.,

 iodinated agents, petrolatum, zinc paste, crystalline sodium chloride,
chlorhexadine gluconate [CHG], bismuth tribromophenate [BTP],
water, aqueous saline, hydrogel, or agents).
IOM: 100-02, 15, 100
❂ A6223 Gauze, impregnated with other than water, normal saline, or
hydrogel, sterile, pad size more than 16 sq. in. but less than or equal
to 48 sq. in., without adhesive border, each dressing N

IOM: 100-02, 15, 100

❂ A6224 Gauze, impregnated with other than water, normal saline, or
hydrogel, sterile, pad size more than 48 sq. in., without adhesive
border, each dressing N

IOM: 100-02, 15, 100

❂ A6228 Gauze, impregnated, water or normal saline, sterile, pad size 16 sq.
in. or less, without adhesive border, each dressing N

IOM: 100-02, 15, 100

❂ A6229 Gauze, impregnated, water or normal saline, sterile, pad size more
than 16 sq. in. but less than or equal to 48 sq. in., without adhesive
border, each dressing N

IOM: 100-02, 15, 100

❂ A6230 Gauze, impregnated, water or normal saline, sterile, pad size more
than 48 sq. in., without adhesive border, each dressing
N
IOM: 100-02, 15, 100
❂ A6231 Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad
size 16 sq. in. or less, each dressing N

IOM: 100-02, 15, 100

❂ A6232 Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad
size greater than 16 sq. in., but less than or equal to 48 sq. in., each
dressing N

IOM: 100-02, 15, 100

❂ A6233 Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad
size more than 48 sq. in., each dressing N

IOM: 100-02, 15, 100

❂ A6234 Hydrocolloid dressing, wound cover, sterile, pad size 16 sq. in. or
less, without adhesive border, each dressing N

This type of dressing is usually used on wounds with light to

moderate exudate with an average of three dressing changes per
week.
 IOM: 100-02, 15, 100
❂ A6235 Hydrocolloid dressing, wound cover, sterile, pad size more than 16
sq. in. but less than or equal to 48 sq. in., without adhesive border,
each dressing N

IOM: 100-02, 15, 100

❂ A6236 Hydrocolloid dressing, wound cover, sterile, pad size more than 48
sq. in., without adhesive border, each dressing N

IOM: 100-02, 15, 100

❂ A6237 Hydrocolloid dressing, wound cover, sterile, pad size 16 sq. in. or
less, with any size adhesive border, each dressing N

IOM: 100-02, 15, 100

❂ A6238 Hydrocolloid dressing, wound cover, sterile, pad size more than 16
sq. in. but less than or equal to 48 sq. in., with any size adhesive
border, each dressing N

IOM: 100-02, 15, 100

❂ A6239 Hydrocolloid dressing, wound cover, sterile, pad size more than 48
sq. in., with any size adhesive border, each dressing N

IOM: 100-02, 15, 100

❂ A6240 Hydrocolloid dressing, wound filler, paste, sterile, per ounce
N

IOM: 100-02, 15, 100

❂ A6241 Hydrocolloid dressing, wound filler, dry form, sterile, per gram
N

IOM: 100-02, 15, 100

❂ A6242 Hydrogel dressing, wound cover, sterile, pad size 16 sq. in. or less,
without adhesive border, each dressing N

Considered medically necessary when used on full thickness

wounds with minimal or no exudate (e.g., stage III or IV ulcers).
Usually up to one dressing change per day is considered medically
necessary, but if well documented and medically necessary, the
payer may allow more frequent dressing changes.
IOM: 100-02, 15, 100
❂ A6243 Hydrogel dressing, wound cover, sterile, pad size more than 16 sq.
in. but less than or equal to 48 sq. in., without adhesive border, each
dressing N

IOM: 100-02, 15, 100

❂ A6244 Hydrogel dressing, wound cover, sterile, pad size more than 48 sq.
 in., without adhesive border, each dressing N

IOM: 100-02, 15, 100

❂ A6245 Hydrogel dressing, wound cover, sterile, pad size 16 sq. in. or less,
with any size adhesive border, each dressing N

Coverage of a non-elastic gradient compression wrap is limited to

one per 6 months per leg.
IOM: 100-02, 15, 100
❂ A6246 Hydrogel dressing, wound cover, sterile, pad size more than 16 sq.
in. but less than or equal to 48 sq. in., with any size adhesive border,
each dressing N

IOM: 100-02, 15, 100

❂ A6247 Hydrogel dressing, wound cover, sterile, pad size more than 48 sq.
in., with any size adhesive border, each dressing N

IOM: 100-02, 15, 100

❂ A6248 Hydrogel dressing, wound filler, gel, per fluid ounce N

IOM: 100-02, 15, 100

❂ A6250 Skin sealants, protectants, moisturizers, ointments, any type, any
size N

IOM: 100-02, 15, 100

❂ A6251 Specialty absorptive dressing, wound cover, sterile, pad size 16 sq.
in. or less, without adhesive border, each dressing N

IOM: 100-02, 15, 100

❂ A6252 Specialty absorptive dressing, wound cover, sterile, pad size more
than 16 sq. in. but less than or equal to 48 sq. in., without adhesive
border, each dressing N

IOM: 100-02, 15, 100

❂ A6253 Specialty absorptive dressing, wound cover, sterile, pad size more
than 48 sq. in., without adhesive border, each dressing N

IOM: 100-02, 15, 100

❂ A6254 Specialty absorptive dressing, wound cover, sterile, pad size 16 sq.
in. or less, with any size adhesive border, each dressing
N
IOM: 100-02, 15, 100
❂ A6255 Specialty absorptive dressing, wound cover, sterile, pad size more
than 16 sq. in. but less than or equal to 48 sq. in., with any size
adhesive border, each dressing N

IOM: 100-02, 15, 100

❂ A6256 Specialty absorptive dressing, wound cover, sterile, pad size more
than 48 sq. in., with any size adhesive border, each dressing
N
Considered medically necessary when used for moderately or highly
exudative wounds (e.g., stage III or IV ulcers).
IOM: 100-02, 15, 100
❂ A6257 Transparent film, sterile, 16 sq. in. or less, each dressing
N
Considered medically necessary when used on open partial
thickness wounds with minimal exudate or closed wounds.
IOM: 100-02, 15, 100
❂ A6258 Transparent film, sterile, more than 16 sq. in. but less than or equal
to 48 sq. in., each dressing N

IOM: 100-02, 15, 100

❂ A6259 Transparent film, sterile, more than 48 sq. in., each dressing
N

IOM: 100-02, 15, 100

❂ A6260 Wound cleansers, any type, any size N

IOM: 100-02, 15, 100

❂ A6261 Wound filler, gel/paste, per fluid ounce, not otherwise specified
N

Units of service for wound fillers are 1 gram, 1 fluid ounce, 6 inch
length, or 1 yard depending on product.
IOM: 100-02, 15, 100
❂ A6262 Wound filler, dry form, per gram, not otherwise specified
Dry forms (e.g., powder, granules, beads) are used to eliminate N
dead space in an open wound.
IOM: 100-02, 15, 100
❂ A6266 Gauze, impregnated, other than water, normal saline, or zinc paste,
sterile, any width, per linear yard N

IOM: 100-02, 15, 100

❂ A6402 Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, without
adhesive border, each dressing N

IOM: 100-02, 15, 100

❂ A6403 Gauze, non-impregnated, sterile, pad size more than 16 sq. in., less
than or equal to 48 sq. in., without adhesive border, each dressing
N

IOM: 100-02, 15, 100

 ❂ A6404 Gauze, non-impregnated, sterile, pad size more than 48 sq. in.,
without adhesive border, each dressing N

IOM: 100-02, 15, 100

✽ A6407 Packing strips, non-impregnated, sterile, up to 2 inches in width, per
linear yard N

IOM: 100-02, 15, 100

❂ A6410 Eye pad, sterile, each N

IOM: 100-02, 15, 100

❂ A6411 Eye pad, non-sterile, each N

IOM: 100-02, 15, 100

✽ A6412 Eye patch, occlusive, each N

Bandages
A6413 Adhesive bandage, first-aid type, any size, each E1

First aid type bandage is a wound cover with a pad size of less than
4 sq. in. Does not meet the definition of the surgical dressing benefit
and will be denied as non-covered.
Medicare Statute 1861(s)(5)
✽ A6441 Padding bandage, non-elastic, nonwoven/non-knitted, width greater
than or equal to three inches and less than five inches, per yard
N
✽ A6442 Conforming bandage, non-elastic, knitted/woven, non-sterile, width
less than three inches, per yard N

Non-elastic, moderate or high compression that is typically

sustained for one week
✽ A6443 Conforming bandage, non-elastic, knitted/woven, non-sterile, width
greater than or equal to three inches and less than five inches, per
yard N

✽ A6444 Conforming bandage, non-elastic, knitted/woven, non-sterile, width

greater than or equal to five inches, per yard N

✽ A6445 Conforming bandage, non-elastic, knitted/woven, sterile, width less

than three inches, per yard N

✽ A6446 Conforming bandage, non-elastic, knitted/woven, sterile, width

greater than or equal to three inches and less than five inches, per
yard N

✽ A6447 Conforming bandage, non-elastic, knitted/woven, sterile, width

greater than or equal to five inches, per yard N
✽ A6448 Light compression bandage, elastic, knitted/woven, width less than
three inches, per yard N

Used to hold wound cover dressings in place over a wound.

Example is an ACE type elastic bandage.
✽ A6449 Light compression bandage, elastic, knitted/woven, width greater
than or equal to three inches and less than five inches, per yard
N
✽ A6450 Light compression bandage, elastic, knitted/woven, width greater
than or equal to five inches, per yard N

✽ A6451 Moderate compression bandage, elastic, knitted/woven, load

resistance of 1.25 to 1.34 foot pounds at 50% maximum stretch,
width greater than or equal to three inches and less than five inches,
per yard N

Elastic bandages that produce moderate compression that is

typically sustained for one week
Medicare considers coverage if part of a multi-layer compression
bandage system for the treatment of a venous stasis ulcer. Do not
assign for strains or sprains.
✽ A6452 High compression bandage, elastic, knitted/woven, load resistance
greater than or equal to 1.35 foot pounds at 50% maximum stretch,
width greater than or equal to three inches and less than five inches,
per yard N

Elastic bandages that produce high compression that is typically

sustained for one week
✽ A6453 Self-adherent bandage, elastic, non-knitted/non-woven, width less
than three inches, per yard N

✽ A6454 Self-adherent bandage, elastic, non-knitted/non-woven, width

greater than or equal to three inches and less than five inches, per
yard N

✽ A6455 Self-adherent bandage, elastic, non-knitted/non-woven, width

greater than or equal to five inches, per yard N

✽ A6456 Zinc paste impregnated bandage, non-elastic, knitted/woven, width

greater than or equal to three inches and less than five inches, per
yard N

✽ A6457 Tubular dressing with or without elastic, any width, per linear yard
N

✽ A6460 Synthetic resorbable wound dressing, sterile, pad size 16 sq. in. or
less, without adhesive border, each dressing N
✽ A6461 Synthetic resorbable wound dressing, sterile, pad size more than 16
sq. in. but less than or equal to 48 sq. in., without adhesive border,
each dressing N
Compression Garments
❂ A6501 Compression burn garment, bodysuit (head to foot), custom
fabricated N

Garments used to reduce hypertrophic scarring and joint

contractures following burn injury
IOM: 100-02, 15, 100
❂ A6502 Compression burn garment, chin strap, custom fabricated
N
IOM: 100-02, 15, 100
❂ A6503 Compression burn garment, facial hood, custom fabricated
N

IOM: 100-02, 15, 100

❂ A6504 Compression burn garment, glove to wrist, custom fabricated
N

IOM: 100-02, 15, 100

❂ A6505 Compression burn garment, glove to elbow, custom fabricated
N

IOM: 100-02, 15, 100

❂ A6506 Compression burn garment, glove to axilla, custom fabricated
N

IOM: 100-02, 15, 100

❂ A6507 Compression burn garment, foot to knee length, custom fabricated
N

IOM: 100-02, 15, 100

❂ A6508 Compression burn garment, foot to thigh length, custom fabricated
N

IOM: 100-02, 15, 100

❂ A6509 Compression burn garment, upper trunk to waist including arm
openings (vest), custom fabricated N

IOM: 100-02, 15, 100

❂ A6510 Compression burn garment, trunk, including arms down to leg
openings (leotard), custom fabricated N

IOM: 100-02, 15, 100

❂ A6511 Compression burn garment, lower trunk including leg openings
(panty), custom fabricated N
 IOM: 100-02, 15, 100
❂ A6512 Compression burn garment, not otherwise classified N

IOM: 100-02, 15, 100

✽ A6513 Compression burn mask, face and/or neck, plastic or equal, custom
fabricated B

A6530 Gradient compression stocking, below knee, 18-30 mmHg, each

E1

IOM: 100-03, 4, 280.1

❂ A6531 Gradient compression stocking, below knee, 30-40 mmHg, each
N

Covered when used in treatment of open venous stasis ulcer.

Modifiers A1-A9 are not assigned. Must be billed with AW, RT, or
LT.
IOM: 100-02, 15, 100
❂ A6532 Gradient compression stocking, below knee, 40-50 mmHg, each
N

Covered when used in treatment of open venous stasis ulcer.

Modifiers A1-A9 are not assigned. Must be billed with AW, RT, or
LT.
IOM: 100-02, 15, 100
A6533 Gradient compression stocking, thigh length, 18-30 mmHg, each
E1

IOM: 100-02, 15, 130; 100-03, 4, 280.1

A6534 Gradient compression stocking, thigh length, 30-40 mmHg, each
E1

IOM: 100-02, 15, 130; 100-03, 4, 280.1

A6535 Gradient compression stocking, thigh length, 40-50 mmHg, each
E1

IOM: 100-02, 15, 130; 100-03, 4, 280.1

A6536 Gradient compression stocking, full length/chap style, 18-30 mmHg,
each E1

IOM: 100-02, 15, 130; 100-03, 4, 280.1

A6537 Gradient compression stocking, full length/chap style, 30-40 mmHg,
each E1

IOM: 100-02, 15, 130; 100-03, 4, 280.1

A6538 Gradient compression stocking, full length/chap style, 40-50 mmHg,
each E1
 IOM: 100-02, 15, 130; 100-03, 4, 280.1
A6539 Gradient compression stocking, waist length, 18-30 mmHg, each
E1

IOM: 100-02, 15, 130; 100-03, 4, 280.1

A6540 Gradient compression stocking, waist length, 30-40 mmHg, each
E1

IOM: 100-02, 15, 130; 100-03, 4, 280.1

A6541 Gradient compression stocking, waist length, 40-50 mmHg, each
E1

IOM: 100-02, 15, 130; 100-03, 4, 280.1

A6544 Gradient compression stocking, garter belt E1

IOM: 100-02, 15, 130; 100-03, 4, 280.1

❂ A6545 Gradient compression wrap, non-elastic, below knee, 30-50 mm hg,
each N

Modifiers RT and/or LT must be appended. When assigned for

bilateral items (left/right) on the same date of service, bill both items
on the same claim line using RT/LT modifiers and 2 units of service.
IOM: 10-02, 15, 100
A6549 Gradient compression stocking/sleeve, not otherwise specified
E1
IOM: 100-02, 15, 130; 100-03, 4, 280.1

Wound Care
✽ A6550 Wound care set, for negative pressure wound therapy electrical
pump, includes all supplies and accessories N

Respiratory Supplies
✽ A7000 Canister, disposable, used with suction pump, each Y

✽ A7001 Canister, non-disposable, used with suction pump, each Y

✽ A7002 Tubing, used with suction pump, each Y

✽ A7003 Administration set, with small volume nonfiltered pneumatic

nebulizer, disposable Y

✽ A7004 Small volume nonfiltered pneumatic nebulizer, disposable

Y
✽ A7005 Administration set, with small volume nonfiltered pneumatic
nebulizer, nondisposable Y

Administration set, with small volume filtered pneumatic nebulizer

✽ A7006 Y

✽ A7007 Large volume nebulizer, disposable, unfilled, used with aerosol

compressor Y

✽ A7008 Large volume nebulizer, disposable, prefilled, used with aerosol

compressor Y

✽ A7009 Reservoir bottle, nondisposable, used with large volume ultrasonic

nebulizer Y

✽ A7010 Corrugated tubing, disposable, used with large volume nebulizer,

100 feet Y

✽ A7012 Water collection device, used with large volume nebulizer

Y
✽ A7013 Filter, disposable, used with aerosol compressor or ultrasonic
generator Y

✽ A7014 Filter, non-disposable, used with aerosol compressor or ultrasonic

generator Y

✽ A7015 Aerosol mask, used with DME nebulizer Y

✽ A7016 Dome and mouthpiece, used with small volume ultrasonic nebulizer
Y

❂ A7017 Nebulizer, durable, glass or autoclavable plastic, bottle type, not

used with oxygen Y

IOM: 100-03, 4, 280.1

✽ A7018 Water, distilled, used with large volume nebulizer, 1000 ml
Y
✽ A7020 Interface for cough stimulating device, includes all components,
replacement only Y

✽ A7025 High frequency chest wall oscillation system vest, replacement for
use with patient owned equipment, each N

✽ A7026 High frequency chest wall oscillation system hose, replacement for
use with patient owned equipment, each Y

✽ A7027 Combination oral/nasal mask, used with continuous positive airway

pressure device, each Y

✽ A7028 Oral cushion for combination oral/nasal mask, replacement only,

each Y

✽ A7029 Nasal pillows for combination oral/nasal mask, replacement only,

pair Y

✽ A7030 Full face mask used with positive airway pressure device, each
Y
✽ A7031 Face mask interface, replacement for full face mask, each
Y
 ✽ A7032 Cushion for use on nasal mask interface, replacement only, each
Y

✽ A7033 Pillow for use on nasal cannula type interface, replacement only,
pair Y

✽ A7034 Nasal interface (mask or cannula type) used with positive airway
pressure device, with or without head strap Y

✽ A7035 Headgear used with positive airway pressure device Y

✽ A7036 Chinstrap used with positive airway pressure device Y

✽ A7037 Tubing used with positive airway pressure device Y

✽ A7038 Filter, disposable, used with positive airway pressure device

Y
✽ A7039 Filter, non disposable, used with positive airway pressure device
Y

✽ A7040 One way chest drain valve N

✽ A7041 Water seal drainage container and tubing for use with implanted
chest tube N

✽ A7044 Oral interface used with positive airway pressure device, each
Y

❂ A7045 Exhalation port with or without swivel used with accessories for
positive airway devices, replacement only Y

IOM: 100-03, 4, 230.17

❂ A7046 Water chamber for humidifier, used with positive airway pressure
device, replacement, each Y

IOM: 100-03, 4, 230.17

✽ A7047 Oral interface used with respiratory suction pump, each
N
✽ A7048 Vacuum drainage collection unit and tubing kit, including all
supplies needed for collection unit change, for use with implanted
catheter, each N

Tracheostomy Supplies
❂ A7501 Tracheostoma valve, including diaphragm, each N

IOM: 100-02, 15, 120

❂ A7502 Replacement diaphragm/faceplate for tracheostoma valve, each
N

IOM: 100-02, 15, 120

❂ A7503 Filter holder or filter cap, reusable, for use in a tracheostoma heat
 and moisture exchange system, each N

IOM: 100-02, 15, 120

❂ A7504 Filter for use in a tracheostoma heat and moisture exchange system,
each N

IOM: 100-02, 15, 120

❂ A7505 Housing, reusable without adhesive, for use in a heat and moisture
exchange system and/or with a tracheostoma valve, each N

IOM: 100-02, 15, 120

❂ A7506 Adhesive disc for use in a heat and moisture exchange system
and/or with tracheostoma valve, any type, each N

IOM: 100-02, 15, 120

❂ A7507 Filter holder and integrated filter without adhesive, for use in a
tracheostoma heat and moisture exchange system, each
N
IOM: 100-02, 15, 120
❂ A7508 Housing and integrated adhesive, for use in a tracheostoma heat and
moisture exchange system and/or with a tracheostoma valve, each
N

IOM: 100-02, 15, 120

❂ A7509 Filter holder and integrated filter housing, and adhesive, for use as a
tracheostoma heat and moisture exchange system, each N

IOM: 100-02, 15, 120

✽ A7520 Tracheostomy/laryngectomy tube, noncuffed, polyvinylchloride
(PVC), silicone or equal, each N

✽ A7521 Tracheostomy/laryngectomy tube, cuffed, polyvinylchloride (PVC),

silicone or equal, each N

✽ A7522 Tracheostomy/laryngectomy tube, stainless steel or equal

(sterilizable and reusable), each N

✽ A7523 Tracheostomy shower protector, each N

✽ A7524 Tracheostoma stent/stud/button, each N

✽ A7525 Tracheostomy mask, each N

✽ A7526 Tracheostomy tube collar/holder, each N

✽ A7527 Tracheostomy/laryngectomy tube plug/stop, each N

Figure 7 Helmet.

Helmets
✽ A8000 Helmet, protective, soft, prefabricated, includes all components and
accessories Y

✽ A8001 Helmet, protective, hard, prefabricated, includes all components and

accessories Y

✽ A8002 Helmet, protective, soft, custom fabricated, includes all components

and accessories Y

✽ A8003 Helmet, protective, hard, custom fabricated, includes all

components and accessories Y

✽ A8004 Soft interface for helmet, replacement only Y

ADMINISTRATIVE, MISCELLANEOUS, AND

INVESTIGATIONAL (A9000-A9999)
NOTE: The following codes do not imply that codes in other sections are
necessarily covered.

Miscellaneous Supplies
❂ A9150 Non-prescription drugs B

IOM: 100-02, 15, 50

A9152 Single vitamin/mineral/trace element, oral, per dose, not otherwise
specified E1

A9153 Multiple vitamins, with or without minerals and trace elements, oral,
per dose, not otherwise specified E1

✽ A9155 Artificial saliva, 30 ml B

Pediculosis (lice infestation) treatment, topical, for administration

A9180 by patient/caretaker E1

A9270 Non-covered item or service E1

IOM: 100-02, 16, 20

A9272 Wound suction, disposable, includes dressing, all accessories and
components, any type, each E1

Medicare Statute 1861(n)

A9273 Cold or hot water bottle, ice cap or collar, heat and/or cold wrap,
any type E1

A9274 External ambulatory insulin delivery system, disposable, each,

includes all supplies and accessories E1

Medicare Statute 1861(n)

A9275 Home glucose disposable monitor, includes test strips E1

A9276 Sensor; invasive (e.g., subcutaneous), disposable, for use with non-
durable medical equipment interstitial continuous glucose
monitoring system, one unit = 1 day supply E1

Medicare Statute 1861(n)

A9277 Transmitter; external, for use with nondurable medical equipment
interstitial continuous glucose monitoring system E1

Medicare Statute 1861(n)

A9278 Receiver (monitor); external, for use with non-durable medical
equipment interstitial continuous glucose monitoring system
E1
Medicare Statute 1861(n)
A9279 Monitoring feature/device, stand-alone or integrated, any type,
includes all accessories, components and electronics, not otherwise
classified E1

Medicare Statute 1861(n)

A9280 Alert or alarm device, not otherwise classified E1

Medicare Statute 1861

A9281 Reaching/grabbing device, any type, any length, each E1

Medicare Statute 1862 SSA

A9282 Wig, any type, each E1

Medicare Statute 1862 SSA

A9283 Foot pressure off loading/supportive device, any type, each
E1
Medicare Statute 1862A(i)13
❂ A9284 Spirometer, non-electronic, includes all accessories N
 ✽ A9285 Inversion/eversion correction device A

A9286 Hygienic item or device, disposable or non-disposable, any type,

each E1

Medicare Statute 1834

A9300 Exercise equipment E1

IOM: 100-02, 15, 110.1; 100-03, 4, 280.1

Supplies for Radiology Procedures (Radiopharmaceuticals)

✽ A9500 Technetium Tc-99m sestamibi, diagnostic, per study dose
N1 N
Should be filed on same claim as procedure code reporting
radiopharmaceutical. Verify with payer definition of a “study.”
Coding Clinic: 2006, Q2, P5
✽ A9501 Technetium Tc-99m teboroxime, diagnostic, per study dose
N1 N
✽ A9502 Technetium Tc-99m tetrofosmin, diagnostic, per study dose
Coding Clinic: 2006, Q2, P5 N1 N

✽ A9503 Technetium Tc-99m medronate, diagnostic, per study dose, up to 30

millicuries N1 N

✽ A9504 Technetium Tc-99m apcitide, diagnostic, per study dose, up to 20

millicuries N1 N

✽ A9505 Thallium Tl-201 thallous chloride, diagnostic, per millicurie

N1 N
✽ A9507 Indium In-111 capromab pendetide, diagnostic, per study dose, up to
10 millicuries N1 N

✽ A9508 Iodine I-131 iobenguane sulfate, diagnostic, per 0.5 millicurie

N1 N
✽ A9509 Iodine I-123 sodium iodide, diagnostic, per millicurie
N1 N
✽ A9510 Technetium Tc-99m disofenin, diagnostic, per study dose, up to 15
millicuries N1 N

✽ A9512 Technetium Tc-99m pertechnetate, diagnostic, per millicurie

N1 N
❂ A9513 Lutetium lu 177, dotatate, therapeutic, 1 millicurie G

✽ A9515 Choline C-11, diagnostic, per study dose up to 20 millicuries

K2 G
✽ A9516 Iodine I-123 sodium iodide, diagnostic, per 100 microcuries, up to
999 microcuries N1 N

✽ A9517 Iodine I-131 sodium iodide capsule(s), therapeutic, per millicurie

K
✽ A9520 Technetium Tc-99m tilmanocept, diagnostic, up to 0.5 millicuries
N1 N

✽ A9521 Technetium Tc-99m exametazime, diagnostic, per study dose, up to

25 millicuries N1 N

✽ A9524 Iodine I-131 iodinated serum albumin, diagnostic, per 5 microcuries

N1 N

✽ A9526 Nitrogen N-13 ammonia, diagnostic, per study dose, up to 40

millicuries N1 N

✽ A9527 Iodine I-125, sodium iodide solution, therapeutic, per millicurie

H2 U

✽ A9528 Iodine I-131 sodium iodide capsule(s), diagnostic, per millicurie

N1 N

✽ A9529 Iodine I-131 sodium iodide solution, diagnostic, per millicurie

N1 N
✽ A9530 Iodine I-131 sodium iodide solution, therapeutic, per millicurie
K
✽ A9531 Iodine I-131 sodium iodide, diagnostic, per microcurie (up to 100
microcuries) N1 N

✽ A9532 Iodine I-125 serum albumin, diagnostic, per 5 microcuries

N1 N
✽ A9536 Technetium Tc-99m depreotide, diagnostic, per study dose, up to 35
millicuries N1 N

✽ A9537 Technetium Tc-99m mebrofenin, diagnostic, per study dose, up to

15 millicuries N1 N

✽ A9538 Technetium Tc-99m pyrophosphate, diagnostic, per study dose, up

to 25 millicuries N1 N

✽ A9539 Technetium Tc-99m pentetate, diagnostic, per study dose, up to 25

millicuries N1 N

✽ A9540 Technetium Tc-99m macroaggregated albumin, diagnostic, per

study dose, up to 10 millicuries N1 N

✽ A9541 Technetium Tc-99m sulfur colloid, diagnostic, per study dose, up to

20 millicuries N1 N

✽ A9542 Indium In-111 ibritumomab tiuxetan, diagnostic, per study dose, up

to 5 millicuries N1 N

Specifically for diagnostic use.

✽ A9543 Yttrium Y-90 ibritumomab tiuxetan, therapeutic, per treatment dose,
up to 40 millicuries K

Specifically for therapeutic use.

✽ A9546 Cobalt Co-57/58, cyanocobalamin, diagnostic, per study dose, up to
1 microcurie N1 N

✽ A9547 Indium In-111 oxyquinoline, diagnostic, per 0.5 millicurie

N1 N
✽ A9548 Indium In-111 pentetate, diagnostic, per 0.5 millicurie
N1 N
✽ A9550 Technetium Tc-99m sodium gluceptate, diagnostic, per study dose,
up to 25 millicuries N1 N

✽ A9551 Technetium Tc-99m succimer, diagnostic, per study dose, up to 10

millicuries N1 N

✽ A9552 Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45

millicuries N1 N
Coding Clinic: 2008, Q3, P7
✽ A9553 Chromium Cr-51 sodium chromate, diagnostic, per study dose, up to
250 microcuries N1 N

✽ A9554 Iodine I-125 sodium Iothalamate, diagnostic, per study dose, up to

10 microcuries N1 N

✽ A9555 Rubidium Rb-82, diagnostic, per study dose, up to 60 millicuries

N1 N

✽ A9556 Gallium Ga-67 citrate, diagnostic, per millicurie N1 N

✽ A9557 Technetium Tc-99m bicisate, diagnostic, per study dose, up to 25

millicuries N1 N

✽ A9558 Xenon Xe-133 gas, diagnostic, per 10 millicuries N1 N

✽ A9559 Cobalt Co-57 cyanocobalamin, oral, diagnostic, per study dose, up

to 1 microcurie N1 N

✽ A9560 Technetium Tc-99m labeled red blood cells, diagnostic, per study
dose, up to 30 millicuries N1 N
Coding Clinic: 2008, Q3, P7
✽ A9561 Technetium Tc-99m oxidronate, diagnostic, per study dose, up to 30
millicuries N1 N

✽ A9562 Technetium Tc-99m mertiatide, diagnostic, per study dose, up to 15

millicuries N1 N

✽ A9563 Sodium phosphate P-32, therapeutic, per millicurie K

✽ A9564 Chromic phosphate P-32 suspension, therapeutic, per millicurie

E1

✽ A9566 Technetium Tc-99m fanolesomab, diagnostic, per study dose, up to

25 millicuries N1 N

✽ A9567 Technetium Tc-99m pentetate, diagnostic, aerosol, per study dose,

 up to 75 millicuries N1 N

✽ A9568 Technetium TC-99m arcitumomab, diagnostic, per study dose, up to

45 millicuries N1 N

✽ A9569 Technetium Tc-99m exametazime labeled autologous white blood

cells, diagnostic, per study dose N1 N

✽ A9570 Indium In-111 labeled autologous white blood cells, diagnostic, per
study dose N1 N

✽ A9571 Indium In-111 labeled autologous platelets, diagnostic, per study

dose N1 N

✽ A9572 Indium In-111 pentetreotide, diagnostic, per study dose, up to 6

millicuries N1 N

✽ A9575 Injection, gadoterate meglumine, 0.1 ml N1 N

Other: Clariscan, Gadoterate Meglumine

✽ A9576 Injection, gadoteridol, (ProHance Multipack), per ml
N1 N
✽ A9577 Injection, gadobenate dimeglumine (MultiHance), per ml
N1 N
✽ A9578 Injection, gadobenate dimeglumine (MultiHance Multipack), per ml
N1 N

✽ A9579 Injection, gadolinium-based magnetic resonance contrast agent, not

otherwise specified (NOS), per ml N1 N

Other: Magnevist, Prohance

✽ A9580 Sodium fluoride F-18, diagnostic, per study dose, up to 30
millicuries N1 N

✽ A9581 Injection, gadoxetate disodium, 1 ml N1 N

Local Medicare contractors may require the use of modifier JW to

identify unused product from single-dose vials that are appropriately
discarded.
Other: Eovist
✽ A9582 Iodine I-123 iobenguane, diagnostic, per study dose, up to 15
millicuries N1 N

Molecular imaging agent that assists in the identification of rare

neuroendocrine tumors.
✽ A9583 Injection, gadofosveset trisodium, 1 ml N1 N

✽ A9584 Iodine 1-123 ioflupane, diagnostic, per study dose, up to 5

millicuries N1 N
Coding Clinic: 2012, Q1, P9
✽ A9585 Injection, gadobutrol, 0.1 ml N1 N
 Other: Gadavist
Coding Clinic: 2012, Q1, P8
❂ A9586 Florbetapir F18, diagnostic, per study dose, up to 10 millicuries
N1 N

✽ A9587 Gallium Ga-68, dotatate, diagnostic, 0.1 millicurie K2 G

Coding Clinic: 2017, Q1, P9
✽ A9589 Instillation, hexaminolevulinate hydrochloride, 100 mg N1 N

✽ A9588 Fluciclovine F-18, diagnostic, 1 millicurie K2 G

Coding Clinic: 2017, Q1, P9
✽ A9590 Iodine I-131, iobenguane, 1 millicurie N

✽ A9591 Fluoroestradiol F 18, diagnostic, 1 millicurie K2 G

✽ A9592 Copper cu-64, dotatate, diagnostic, 1 millicurie K2 G

✽ A9593 Gallium ga-68 psma-11, diagnostic, (ucsf), 1 millicurie K2 G

✽ A9594 Gallium ga-68 psma-11, diagnostic, (ucla), 1 millicurie K2 G

✽ A9595 Piflufolastat f-18, diagnostic, 1 millicurie K2 G

▶ A9596 Gallium GA-68 gozetotide, diagnostic, (illuccix), 1 millicurie

✽ A9597 Positron emission tomography radiopharmaceutical, diagnostic, for
tumor identification, not otherwise classified N1 N
Coding Clinic: 2017, Q1, P8-9
✽ A9598 Positron emission tomography radiopharmaceutical, diagnostic, for
non-tumor identification, not otherwise classified N1 N
Coding Clinic: 2017, Q1, P8-9
✽ A9600 Strontium Sr-89 chloride, therapeutic, per millicurie K

▶ A9601 Flortaucipir F 18 injection, diagnostic, 1 millicurie K5 K

▶ A9602 Fluorodopa F-18, diagnostic, per millicurie K2 K

✽ A9604 Samarium SM-153 lexidronam, therapeutic, per treatment dose, up

to 150 millicuries K

✽ A9606 Radium Ra-223 dichloride, therapeutic, per microcurie K

▶ A9607 Lutetium LU 177 vipivotide tetraxetan, therapeutic, 1 millicurie K

❂ A9698 Non-radioactive contrast imaging material, not otherwise classified,

per study N1 N

IOM: 100-04, 12, 70; 100-04, 13, 20

Coding Clinic: 2017, Q1, P8
✽ A9699 Radiopharmaceutical, therapeutic, not otherwise classified N
 ❂ A9700 Supply of injectable contrast material for use in echocardiography,
per study N1 N

IOM: 100-04, 12, 30.4

Coding Clinic: 2017, Q1, P8
▶ A9800 Gallium GA-68 gozetotide, diagnostic, (locametz), 1 millicurie
K2 K

Miscellaneous Service Component

✽ A9900 Miscellaneous DME supply, accessory, and/or service component of
another HCPCS code Y

On DMEPOS fee schedule as a payable replacement for

miscellaneous implanted or non-implanted items.
✽ A9901 DME delivery, set up, and/or dispensing service component of
another HCPCS code A

✽ A9999 Miscellaneous DME supply or accessory, not otherwise specified

Y
On DMEPOS fee schedule as a payable replacement for
miscellaneous implanted or non-implanted items.

ENTERAL AND PARENTERAL THERAPY (B4000-B9999)

Enteral Feeding Supplies
❂ B4034 Enteral feeding supply kit; syringe fed, per day, includes but not
limited to feeding/flushing syringe, administration set tubing,
dressings, tape Y

Dressings used with gastrostomy tubes for enteral nutrition (covered

under the prosthetic device benefit) are included in the payment.
IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2
PEN: On Fee Schedule
❂ B4035 Enteral feeding supply kit; pump fed, per day, includes but not
limited to feeding/flushing syringe, administration set tubing,
dressings, tape Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4036 Enteral feeding supply kit; gravity fed, per day, includes but not
limited to feeding/flushing syringe, administration set tubing,
dressings, tape Y
 IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2
PEN: On Fee Schedule
❂ B4081 Nasogastric tubing with stylet Y

More than 3 nasogastric tubes (B4081-B4083), or 1

gastrostomy/jejunostomy tube (B4087-B4088) every three months is
rarely medically necessary.
IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2
PEN: On Fee Schedule
❂ B4082 Nasogastric tubing without stylet Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4083 Stomach tube - Levine type Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
✽ B4087 Gastrostomy/jejunostomy tube, standard, any material, any type,
each A

PEN: On Fee Schedule

✽ B4088 Gastrostomy/jejunostomy tube, lowprofile, any material, any type,
each A

PEN: On Fee Schedule

Enteral Formulas and Additives

B4100 Food thickener, administered orally, per ounce E1

❂ B4102 Enteral formula, for adults, used to replace fluids and electrolytes
(e.g., clear liquids), 500 ml = 1 unit Y

IOM: 100-03, 3, 180.2

❂ B4103 Enteral formula, for pediatrics, used to replace fluids and
electrolytes (e.g., clear liquids), 500 ml = 1 unit Y

IOM: 100-03, 3, 180.2

❂ B4104 Additive for enteral formula (e.g., fiber) E1

IOM: 100-03, 3, 180.2

❂ B4105 In-line cartridge containing digestive enzyme(s) for enteral feeding,
each Y

Cross Reference Q9994

❂ B4149 Enteral formula, manufactured blenderized natural foods with intact
 nutrients, includes proteins, fats, carbohydrates, vitamins and
minerals, may include fiber, administered through an enteral feeding
tube, 100 calories = 1 unit Y

Produced to meet unique nutrient needs for specific disease

conditions; medical record must document specific condition and
need for special nutrient.
IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2
PEN: On Fee Schedule
❂ B4150 Enteral formulae, nutritionally complete with intact nutrients,
includes proteins, fats, carbohydrates, vitamins, and minerals, may
include fiber, administered through an enteral feeding tube, 100
calories = 1 unit Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4152 Enteral formula, nutritionally complete, calorically dense (equal to
or greater than 1.5 kcal/ml) with intact nutrients, includes proteins,
fats, carbohydrates, vitamins and minerals, may include fiber,
administered through an enteral feeding tube, 100 calories = 1 unit
Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4153 Enteral formula, nutritionally complete, hydrolyzed proteins (amino
acids and peptide chain), includes fats, carbohydrates, vitamins and
minerals, may include fiber, administered through an enteral feeding
tube, 100 calories = 1 unit Y

If 2 enteral nutrition products described by same HCPCS code and

provided at same time billed on single claim line with units of
service reflecting total calories of both nutrients
IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2
PEN: On Fee Schedule
❂ B4154 Enteral formula, nutritionally complete, for special metabolic needs,
excludes inherited disease of metabolism, includes altered
composition of proteins, fats, carbohydrates, vitamins and/or
minerals, may include fiber, administered through an enteral feeding
tube, 100 calories = 1 unit Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4155 Enteral formula, nutritionally incomplete/modular nutrients,
 includes specific nutrients, carbohydrates (e.g., glucose polymers),
proteins/amino acids (e.g., glutamine, arginine), fat (e.g., medium
chain triglycerides) or combination, administered through an enteral
feeding tube, 100 calories = 1 unit Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4157 Enteral formula, nutritionally complete, for special metabolic needs
for inherited disease of metabolism, includes proteins, fats,
carbohydrates, vitamins and minerals, may include fiber,
administered through an enteral feeding tube, 100 calories = 1 unit
Y

IOM: 100-03, 3, 180.2

❂ B4158 Enteral formula, for pediatrics, nutritionally complete with intact
nutrients, includes proteins, fats, carbohydrates, vitamins and
minerals, may include fiber and/or iron, administered through an
enteral feeding tube, 100 calories = 1 unit Y

IOM: 100-03, 3, 180.2

❂ B4159 Enteral formula, for pediatrics, nutritionally complete soy based
with intact nutrients, includes proteins, fats, carbohydrates, vitamins
and minerals, may include fiber and/or iron, administered through
an enteral feeding tube, 100 calories = 1 unit Y

IOM: 100-03, 3, 180.2

❂ B4160 Enteral formula, for pediatrics, nutritionally complete calorically
dense (equal to or greater than 0.7 kcal/ml) with intact nutrients,
includes proteins, fats, carbohydrates, vitamins and minerals, may
include fiber, administered through an enteral feeding tube, 100
calories = 1 unit Y

IOM: 100-03, 3, 180.2

❂ B4161 Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide
chain proteins, includes fats, carbohydrates, vitamins and minerals,
may include fiber, administered through an enteral feeding tube, 100
calories = 1 unit Y

IOM: 100-03, 3, 180.2

❂ B4162 Enteral formula, for pediatrics, special metabolic needs for inherited
disease of metabolism, includes proteins, fats, carbohydrates,
vitamins and minerals, may include fiber, administered through an
enteral feeding tube, 100 calories = 1 unit Y

IOM: 100-03, 3, 180.2

Figure 8 Total Parenteral Nutrition (TPN) involves percutaneous placement of central
venous catheter into vena cava or right atrium.

Parenteral Nutritional Solutions and Supplies

❂ B4164 Parenteral nutrition solution: carbohydrates (dextrose), 50% or less
(500 ml = 1 unit) - home mix Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4168 Parenteral nutrition solution; amino acid, 3.5%, (500 ml = 1 unit) -
home mix Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4172 Parenteral nutrition solution; amino acid, 5.5% through 7%, (500 ml
= 1 unit) - home mix Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

❂ B4176 Parenteral nutrition solution; amino acid, 7% through 8.5%, (500 ml
= 1 unit) - home mix Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4178 Parenteral nutrition solution: amino acid, greater than 8.5% (500 ml
= 1 unit) - home mix Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

 PEN: On Fee Schedule
❂ B4180 Parenteral nutrition solution; carbohydrates (dextrose), greater than
50% (500 ml = 1 unit) - home mix Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4185 Parenteral nutrition solution, not otherwise specified, 10 grams
lipids B

PEN: On Fee Schedule

❂ B4187 Omegaven, 10 grams lipids Y

❂ B4189 Parenteral nutrition solution; compounded amino acid and

carbohydrates with electrolytes, trace elements, and vitamins,
including preparation, any strength, 10 to 51 grams of protein -
premix Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4193 Parenteral nutrition solution; compounded amino acid and
carbohydrates with electrolytes, trace elements, and vitamins,
including preparation, any strength, 52 to 73 grams of protein -
premix Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4197 Parenteral nutrition solution; compounded amino acid and
carbohydrates with electrolytes, trace elements and vitamins,
including preparation, any strength, 74 to 100 grams of protein -
premix Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4199 Parenteral nutrition solution; compounded amino acid and
carbohydrates with electrolytes, trace elements and vitamins,
including preparation, any strength, over 100 grams of protein -
premix Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4216 Parenteral nutrition; additives (vitamins, trace elements, heparin,
electrolytes) home mix per day Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
 ❂ B4220 Parenteral nutrition supply kit; premix, per day Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4222 Parenteral nutrition supply kit; home mix, per day Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4224 Parenteral nutrition administration kit, per day Y

Dressings used with parenteral nutrition (covered under the

prosthetic device benefit) are included in the payment.
(https://www.cms.gov/medicare-coverage-database/search.aspx)
IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2
PEN: On Fee Schedule
❂ B5000 Parenteral nutrition solution compounded amino acid and
carbohydrates with electrolytes, trace elements, and vitamins,
including preparation, any strength, renal - Aminosyn-RF,
NephrAmine, RenAmine - premix Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B5100 Parenteral nutrition solution compounded amino acid and
carbohydrates with electrolytes, trace elements, and vitamins,
including preparation, any strength, hepatic, HepatAmine - premix
Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B5200 Parenteral nutrition solution compounded amino acid and
carbohydrates with electrolytes, trace elements, and vitamins,
including preparation, any strength, stress-branch chain amino
acids-FreAmine-HBC - premix Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

Enteral and Parenteral Pumps

❂ B9002 Enteral nutrition infusion pump, any type Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B9004 Parenteral nutrition infusion pump, portable Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

 PEN: On Fee Schedule
❂ B9006 Parenteral nutrition infusion pump, stationary Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B9998 NOC for enteral supplies Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

❂ B9999 NOC for parenteral supplies Y

Determine if an alternative HCPCS Level II or a CPT code better

describes the service being reported. This code should be reported
only if a more specific code is unavailable.
IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

CMS HOSPITAL OUTPATIENT PAYMENT SYSTEM

(C1000-C9999)
NOTE: C-codes are used on Medicare Ambulatory Surgical Center (ASC) and
Hospital Outpatient Prospective Payment System (OPPS) claims, but may also
be recognized on claims from other providers or by other payment systems. As
of 10/01/2006, the following non-OPPS providers have been able to bill
Medicare using the C-codes, or an appropriate CPT code on Types of Bill
(TOBs) 12X, 13X, or 85X:
• Critical Access Hospitals (CAHs);
• Indian Health Service Hospitals (IHS);
• Hospitals located in American Samoa, Guam, Saipan or the Virgin Islands; and
• Maryland waiver hospitals.
The billing of C-codes by Method I and Method II Critical Access Hospitals
(CAHs) is limited to the billing for facility (technical) services. The C-codes
shall not be billed by Method II CAHs for professional services with revenue
codes (RCs) 96X, 97X, or 98X.
C codes are updated quarterly by the Centers for Medicare and Medicaid
Services (CMS).

Devices and Supplies

❂ C1052 Hemostatic agent, gastrointestinal, topical J7 H
 ❂ C1062 Intravertebral body fracture augmentation with implant (e.g., metal,
polymer) J7 H

❂ C1713 Anchor/Screw for opposing bone-to-bone or soft tissue-to-bone

(implantable) N1 N

Medicare Statute 1833(t)

Coding Clinic: 2022, Q3, P9; 2021, Q1, P9-10; 2020, Q4, P7-8; 2018, Q2, P5; Q1, P4;
2016, Q3, P16; 2015, Q3, P2; 2010, Q2, P3
❂ C1714 Catheter, transluminal atherectomy, directional N1 N

Medicare Statute 1833(t)

❂ C1715 Brachytherapy needle N1 N

Medicare Statute 1833(t)

Brachytherapy Sources
❂ C1716 Brachytherapy source, non-stranded, gold-198, per source
H2 U
Medicare Statute 1833(t)

Figure 9 (A) Brachytherapy device, (B) Brachytherapy device inserted.

❂ C1717 Brachytherapy source, non-stranded, high dose rate iridium 192, per
source H2 U

Medicare Statute 1833(t)

❂ C1719 Brachytherapy source, non-stranded, non-high dose rate iridium-
192, per source H2 U

Medicare Statute 1833(t)

Cardioverter-Defibrilators
❂ C1721 Cardioverter-defibrillator, dual chamber (implantable) N1 N

Related CPT codes: 33224, 33240, 33249.

Medicare Statute 1833(t)
 ❂ C1722 Cardioverter-defibrillator, single chamber (implantable)
N1 N
Related CPT codes: 33240, 33249.
Medicare Statute 1833(t)
Coding Clinic: 2017, Q2, P5; 2006, Q2, P9

Catheters
❂ C1724 Catheter, transluminal atherectomy, rotational N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P9
❂ C1725 Catheter, transluminal angioplasty, non-laser (may include guidance,
infusion/perfusion capability) N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P16, P19
❂ C1726 Catheter, balloon dilatation, nonvascular N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P16, P19
❂ C1727 Catheter, balloon tissue dissector, non-vascular (insertable)
N1 N
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P16
❂ C1728 Catheter, brachytherapy seed administration N1 N

Medicare Statute 1833(t)

❂ C1729 Catheter, drainage N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P17
❂ C1730 Catheter, electrophysiology, diagnostic, other than 3D mapping (19
or fewer electrodes) N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P17
❂ C1731 Catheter, electrophysiology, diagnostic, other than 3D mapping (20
or more electrodes) N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P17
❂ C1732 Catheter, electrophysiology, diagnostic/ablation, 3D or vector
mapping N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P15, P17, P19
❂ C1733 Catheter, electrophysiology, diagnostic/ablation, other than 3D or
 vector mapping, other than cool-tip N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P17
❂ C1734 Orthopedic/device/drug matrix for opposing bone-to-bone or soft
tissue-to-bone (implantable) N1

▶ C1747 Endoscope, single-use (i.e. disposable), urinary tract,

imaging/illumination device (insertable) J7 H

❂ C1748 Endoscope, single-use (i.e. disposable), upper gi,

imaging/illumination device (insertable) J7 H

❂ C1749 Endoscope, retrograde imaging/illumination colonoscope device

(implantable) N1 N

Medicare Statute 1833(t)

❂ C1750 Catheter, hemodialysis/peritoneal, long-term N1 N

Medicare Statute 1833(t)

Coding Clinic: 2015, Q4, P6
❂ C1751 Catheter, infusion, inserted peripherally, centrally, or midline (other
than hemodialysis) N1 N

Medicare Statute 1833(t)

❂ C1752 Catheter, hemodialysis/peritoneal, short-term N1 N

Medicare Statute 1833(t)

❂ C1753 Catheter, intravascular ultrasound N1 N

Medicare Statute 1833(t)

❂ C1754 Catheter, intradiscal N1 N

Medicare Statute 1833(t)

❂ C1755 Catheter, instraspinal N1 N

Medicare Statute 1833(t)

❂ C1756 Catheter, pacing, transesophageal N1 N

Medicare Statute 1833(t)

❂ C1757 Catheter, thrombectomy/embolectomy N1 N

Medicare Statute 1833(t)

❂ C1758 Catheter, ureteral N1 N

Medicare Statute 1833(t)

❂ C1759 Catheter, intracardiac echocardiography N1 N

Medicare Statute 1833(t)

Devices
❂ C1760 Closure device, vascular (implantable/insertable) N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P19
❂ C1761 Catheter, transluminal intravascular lithotripsy, coronary J7

❂ C1762 Connective tissue, human (includes fascia lata) N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P9, P16, P19; 2015, Q3, P2; 2003, Q3, P12
❂ C1763 Connective tissue, non-human (includes synthetic) N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P9, P17, P19; 2010, Q4, P3; Q2, P3; 2003, Q3, P12
❂ C1764 Event recorder, cardiac (implantable) N1 N

Medicare Statute 1833(t)

Coding Clinic: 2015, Q2, P8
❂ C1765 Adhesion barrier N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P16
❂ C1766 Introducer/sheath, guiding, intracardiac electrophysiological,
steerable, other than peel-away N1 N

Medicare Statute 1833(t)

❂ C1767 Generator, neurostimulator (implantable), nonrechargeable
N1 N
Related CPT codes: 61885, 61886, 63685, 64590.
Medicare Statute 1833(t)
Coding Clinic: 2021, Q1, P8; 2007, Q1, P8
❂ C1768 Graft, vascular N1 N

Medicare Statute 1833(t)

❂ C1769 Guide wire N1 N

Medicare Statute 1833(t)

Coding Clinic: 2019, Q3, P10; 2016, Q3, P3; 2007, Q2, P7-8
❂ C1770 Imaging coil, magnetic reasonance (insertable) N1 N

Medicare Statute 1833(t)

❂ C1771 Repair device, urinary, incontinence, with sling graft N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P19; 2008, Q3, P7
❂ C1772 Infusion pump, programmable (implantable) N1 N

Medicare Statute 1833(t)

❂ C1773 Retrieval device, insertable (used to retrieve fractured medical
 devices) N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P19
❂ C1776 Joint device (implantable) N1 N

Medicare Statute 1833(t)

Coding Clinic: 2020, Q1, P16; 2018, Q3, P6; 2016, Q3, P3, P18; 2010, Q3, P6; 2008,
Q4, P10
❂ C1777 Lead, cardioverter-defibrillator, endocardial single coil
(implantable) N1 N

Related CPT codes: 33216, 33217, 33249.

Medicare Statute 1833(t)
Coding Clinic: 2017, Q2, P5; 2006, Q2, P9
❂ C1778 Lead, neurostimulator (implantable) N1 N

Related CPT codes: 43647, 63650, 63655, 63663, 63664, 64553,

64555, 64560, 64561, 64565, 64573, 64575, 64577, 64580, 64581.
Medicare Statute 1833(t)
Coding Clinic: 2021, Q1, P8; 2019, Q1, P5; 2007, Q1, P8
❂ C1779 Lead, pacemaker, trasvenous VDD single pass N1 N

Related CPT codes: 33206, 33207, 33208, 33210, 33211, 33214,

33216, 33217, 33249.
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P19
❂ C1780 Lens, intraocular (new technology) N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P18
❂ C1781 Mesh (implantable) N1 N

Medicare Statute 1833(t)

Coding Clinic: 2019, Q1, P5; 2016, Q3, P18-19; 2012, Q2, P3; 2010, Q2, P2-3
❂ C1782 Morcellator N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P18
❂ C1783 Ocular implant, aqueous drainage assist device N1 N

Medicare Statute 1833(t)

Coding Clinic: 2017, Q1, P5
❂ C1784 Ocular device, intraoperative, detached retina N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P18
 ❂ C1785 Pacemaker, dual chamber, rateresponsive (implantable)
N1 N
Related CPT codes: 33206, 33207, 33208, 33213, 33214,
33224.
Medicare Statute 1833(t)

Figure 10 (A) Single pacemaker, (B) Dual pacemaker, (C) Biventricular pacemaker.

❂ C1786 Pacemaker, single chamber, rateresponsive (implantable)

N1 N
Related CPT codes: 33206, 33207, 33212.
Medicare Statute 1833(t)
❂ C1787 Patient programmer, neurostimulator N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P19
❂ C1788 Port, indwelling (implantable) N1 N

Medicare Statute 1833(t)

❂ C1789 Prosthesis, breast (implantable) N1 N

Medicare Statute 1833(t)

❂ C1813 Prosthesis, penile, inflatable ♂ N1 N

Medicare Statute 1833(t)

❂ C1814 Retinal tamponade device, silicone oil N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P19; 2006, Q2, P9
❂ C1815 Prosthesis, urinary sphincter (implantable) N1 N

Medicare Statute 1833(t)

❂ C1816 Receiver and/or transmitter, neurostimulator (implantable)
N1 N
Medicare Statute 1833(t)
❂ C1817 Septal defect implant system, intracardiac N1 N

Medicare Statute 1833(t)

 Coding Clinic: 2016, Q3, P19
❂ C1818 Integrated keratoprosthesic N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P18
❂ C1819 Surgical tissue localization and excision device (implantable)
N1 N
Medicare Statute 1833(t)
❂ C1820 Generator, neurostimulator (implantable), with rechargeable battery
and charging system N1 N

Related CPT codes: 61885, 61886, 63685, 64590.

Medicare Statute 1833(t)
Coding Clinic: 2016, Q2, P7
❂ C1821 Interspinous process distraction device (implantable) N1 N

Medicare Statute 1833(t)

❂ C1822 Generator, neurostimulator (implantable), high frequency, with
rechargeable battery and charging system N1 N

Medicare Statute 1833(T)

Coding Clinic: 2016, Q2, P7
❂ C1823 Generator, neurostimulator (implantable), non-rechargeable, with
transvenous sensing and stimulation leads H

Medicare Statute 1833(t)

❂ C1824 Generator, cardiac contractility modulation (implantable) N1

❂ C1825 Generator, neurostimulator (implantable), non-rechargeable with

carotid sinus baroreceptor stimulation lead(s) J7 H

▶ ❂ C1826 Generator, neurostimulator (implantable), includes closed feedback

loop leads and all implantable components, with rechargeable
battery and charging system J7 H

▶ ❂ C1827 Generator, neurostimulator (implantable), non-rechargeable, with

implantable stimulation lead and external paired stimulation
controller J7 H

❂ C1830 Powered bone marrow biopsy needle N1 N

Medicare Statute 1833(t)

❂ C1831 Interbody cage, anterior, lateral or posterior, personalized
(implantable) J7 H

❂ C1832 Autograft suspension, including cell processing and application, and

all system components J7 H
 ❂ C1833 Monitor, cardiac, including intracardiac lead and all system
components (implantable) J7 H

▶ ❂ C1834 Pressure sensor system, includes all components (e.g., introducer,

sensor), intramuscular (implantable), excludes mobile (wireless)
software application J7 H

❂ C1839 Iris prosthesis N1

❂ C1840 Lens, intraocular (telescopic) N1 N

Medicare Statute 1833(t)

Coding Clinic: 2012, Q3, P10
C1841 Retinal prosthesis, includes all internal and external ✖
components
C1842 Retinal prosthesis, includes all internal and external ✖
components; add-on to C1841
C1849 Skin substitute, synthetic, resorbable, per square centimeter ✖
❂ C1874 Stent, coated/covered, with delivery system N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P16-17, P19
❂ C1875 Stent, coated/covered, without delivery system N1 N

Medicare Statute 1833(t)

Coding Clinic: 2020, Q2, P9; 2016, Q3, P16-17
❂ C1876 Stent, non-coated/non-covered, with delivery system N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P19
❂ C1877 Stent, non-coated/non-covered, without delivery system N1 N

Medicare Statute 1833(t)

❂ C1878 Material for vocal cord medialization, synthetic (implantable)
N1 N
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P18
❂ C1880 Vena cava filter N1 N

Medicare Statute 1833(t)

❂ C1881 Dialysis access system (implantable) N1 N

Medicare Statute 1833(t)

❂ C1882 Cardioverter-defibrillator, other than single or dual chamber
(implantable) N1 N

Related CPT codes: 33224, 33240, 33249.

Medicare Statute 1833(t)
 Coding Clinic: 2016, Q3, P16; 2012, Q2, P9; 2006, Q2, P9
❂ C1883 Adapter/Extension, pacing lead or neurostimulator lead
(implantable) N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P15, P17; 2007, Q1, P8
❂ C1884 Embolization protective system N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P17
❂ C1885 Catheter, transluminal angioplasty, laser N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, p16, Q1, P5
❂ C1886 Catheter, extravascular tissue ablation, any modality (insertable)
N1 N
Medicare Statute 1833(t)
❂ C1887 Catheter, guiding (may include infusion/perfusion capability)
N1 N
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P17
❂ C1888 Catheter, ablation, non-cardiac, endovascular (implantable)
N1 N
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P16
❂ C1889 Implantable/insertable device, not otherwise classified N1 N

Medicare Statute 1833(T)

❂ C1891 Infusion pump, non-programmable, permanent (implantable)
N1 N
Medicare Statute 1833(t)
❂ C1892 Introducer/sheath, guiding, intracardiac electrophysiological, fixed-
curve, peel-away N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P19
❂ C1893 Introducer/sheath, guiding, intracardiac electrophysiological, fixed-
curve, other than peel-away N1 N

Medicare Statute 1833(t)

❂ C1894 Introducer/sheath, other than guiding, other than intracardiac
electrophysiological, non-laser N1 N

Medicare Statute 1833(t)

❂ C1895 Lead, cardioverter-defibrillator, endocardial dual coil (implantable)
N1 N
Related CPT codes: 33216, 33217, 33249.
 Medicare Statute 1833(t)
Coding Clinic: 2006, Q2, P9
❂ C1896 Lead, cardioverter-defibrillator, other than endocardial single or dual
coil (implantable) N1 N

Related CPT codes: 33216, 33217, 33249.

Medicare Statute 1833(t)
❂ C1897 Lead, neurostimulator test kit (implantable) N1 N

Related CPT codes: 43647, 63650, 63655, 63663, 63664, 64553,

64555, 64560, 64561, 64565, 64575, 64577, 64580, 64581.
Medicare Statute 1833(t)
Coding Clinic: 2007, Q1, P8
❂ C1898 Lead, pacemaker, other than transvenous VDD single pass
N1 N
Related CPT codes: 33206, 33207, 33208, 33210, 33211,
33214, 33216, 33217, 33249.
Medicare Statute 1833(t)
Coding Clinic: 2002, Q3, P8
❂ C1899 Lead, pacemaker/cardioverter-defibrillator combination
(implantable) N1 N

Related CPT codes: 33216, 33217, 33249.

Medicare Statute 1833(t)
❂ C1900 Lead, left ventricular coronary venous system N1 N

Related CPT codes: 33224, 33225.

Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P18
❂ C1982 Catheter, pressure-generating, one-way valve, intermittently
occlusive N1

❂ C2596 Probe, image-guided, robotic, waterjet ablation N1 H

❂ C2613 Lung biopsy plug with delivery system N1 H

Medicare Statute 1833(t)

Coding Clinic: 2015, Q2, P11
❂ C2614 Probe, percutaneous lumbar discectomy N1 N

Medicare Statute 1833(t)

❂ C2615 Sealant, pulmonary, liquid N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P18
Brachytherapy Source
❂ C2616 Brachytherapy source, non-stranded, yttrium-90, per source
H2 U
Medicare Statute 1833(t)

Cardiovascular and Genitourinary Devices

❂ C2617 Stent, non-coronary, temporary, without delivery system N1 N

Medicare Statute 1833(t)

Coding Clinic: 2018, Q1, P4; 2016, Q3, P3, P19
❂ C2618 Probe/needle, cryoablation N1 N

Medicare Statute 1833(t)

❂ C2619 Pacemaker, dual chamber, non rateresponsive (implantable)
N1 N
Related CPT codes: 33206, 33207, 33208, 33213, 33214,
33224.
Medicare Statute 1833(t)
❂ C2620 Pacemaker, single chamber, non rateresponsive (implantable)
N1 N
Related CPT codes: 33206, 33207, 33212, 33224.
Medicare Statute 1833(t)
❂ C2621 Pacemaker, other than single or dual chamber (implantable)
N1 N
Related CPT codes: 33206, 33207, 33208, 33212, 33213,
33214, 33224.
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P18; 2002, Q3, P8
❂ C2622 Prosthesis, penile, noninflatable ♂ N1 N

Medicare Statute 1833(t)

❂ C2623 Catheter, transluminal angioplasty, drug-coated, non-laser
N1 N
Medicare Statute 1833(t)
❂ C2624 Implantable wireless pulmonary artery pressure sensor with delivery
catheter, including all system components N1 N

Medicare Statute 1833(t)

Coding Clinic: 2015, Q3, P2
❂ C2625 Stent, non-coronary, temporary, with delivery system N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P19; 2015, Q2, P9
❂ C2626 Infusion pump, non-programmable, temporary (implantable)
N1 N
Medicare Statute 1833(t)
 Coding Clinic: 2016, Q3, P18
❂ C2627 Catheter, suprapubic/cystoscopic N1 N

Medicare Statute 1833(t)

❂ C2628 Catheter, occlusion N1 N

Medicare Statute 1833(t)

❂ C2629 Introducer/Sheath, other than guiding, other than intracardiac
electrophysiological, laser N1 N

Medicare Statute 1833(t)

❂ C2630 Catheter, electrophysiology, diagnostic/ablation, other than 3D or
vector mapping, cool-tip N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P17
❂ C2631 Repair device, urinary, incontinence, without sling graft
N1 N
Medicare Statute 1833(t)

Brachytherapy Sources
❂ C2634 Brachytherapy source, non-stranded, high activity, iodine-125,
greater than 1.01 mci (NIST), per source H2 U

Medicare Statute 1833(t)

❂ C2635 Brachytherapy source, non-stranded, high activity, palladium-103,
greater than 2.2 mci (NIST), per source H2 U

Medicare Statute 1833(t)

❂ C2636 Brachytherapy linear source, non-stranded, palladium-103, per 1
mm H2 U

❂ C2637 Brachytherapy source, non-stranded, Ytterbium-169, per source

B
Medicare Statute 1833(t)
❂ C2638 Brachytherapy source, stranded, iodine-125, per source
H2 U
Medicare Statute 1833(t)(2)
❂ C2639 Brachytherapy source, non-stranded, iodine-125, per source
H2 U
Medicare Statute 1833(t)(2)
❂ C2640 Brachytherapy source, stranded, palladium-103, per source
H2 U
Medicare Statute 1833(t)(2)
❂ C2641 Brachytherapy source, non-stranded, palladium-103, per source
H2 U
Medicare Statute 1833(t)(2)
 ❂ C2642 Brachytherapy source, stranded, cesium-131, per source
H2 U
Medicare Statute 1833(t)(2)
❂ C2643 Brachytherapy source, non-stranded, cesium-131, per source
H2 U
Medicare Statute 1833(t)(2)
❂ C2644 Brachytherapy source, Cesium-131 chloride solution, per millicurie
H2 U

Medicare Statute 1833(t)

❂ C2645 Brachytherapy planar source, palladium-103, per square millimeter
H2 U

Medicare Statute 1833(T)

❂ C2698 Brachytherapy source, stranded, not otherwise specified, per source
H2 U
Medicare Statute 1833(t)(2)
❂ C2699 Brachytherapy source, non-stranded, not otherwise specified, per
source H2 U

Medicare Statute 1833(t)(2)

Skin Substitute Graft Application

❂ C5271 Application of low cost skin substitute graft to trunk, arms, legs,
total wound surface area up to 100 sq cm; first 25 sq cm or less
wound surface area T

Medicare Statute 1833(t)

❂ C5272 Application of low cost skin substitute graft to trunk, arms, legs,
total wound surface area up to 100 sq cm; each additional 25 sq cm
wound surface area, or part thereof (list separately in addition to
code for primary procedure) N

Medicare Statute 1833(t)

❂ C5273 Application of low cost skin substitute graft to trunk, arms, legs,
total wound surface area greater than or equal to 100 sq cm; first
100 sq cm wound surface area, or 1% of body area of infants and
children T

Medicare Statute 1833(t)

❂ C5274 Application of low cost skin substitute graft to trunk, arms, legs,
total wound surface area greater than or equal to 100 sq cm; each
additional 100 sq cm wound surface area, or part thereof, or each
additional 1% of body area of infants and children, or part thereof
(list separately in addition to code for primary procedure)
N
Medicare Statute 1833(t)
❂ C5275 Application of low cost skin substitute graft to face, scalp, eyelids,
mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple
digits, total wound surface area up to 100 sq cm; first 25 sq cm or
less wound surface area T

Medicare Statute 1833(t)

❂ C5276 Application of low cost skin substitute graft to face, scalp, eyelids,
mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple
digits, total wound surface area up to 100 sq cm; each additional 25
sq cm wound surface area, or part thereof (list separately in addition
to code for primary procedure) N

Medicare Statute 1833(t)

❂ C5277 Application of low cost skin substitute graft to face, scalp, eyelids,
mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple
digits, total wound surface area greater than or equal to 100 sq cm;
first 100 sq cm wound surface area, or 1% of body area of infants
and children T

Medicare Statute 1833(t)

❂ C5278 Application of low cost skin substitute graft to face, scalp, eyelids,
mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple
digits, total wound surface area greater than or equal to 100 sq cm;
each additional 100 sq cm wound surface area, or part thereof, or
each additional 1% of body area of infants and children, or part
thereof (list separately in addition to code for primary procedure)
N

Medicare Statute 1833(t)

▶ C7500 Debridement, bone including epidermis, dermis, subcutaneous
tissue, muscle and/or fascia, if performed, first 20 sq cm or less with
manual preparation and insertion of deep (eg, subfacial) drug-
delivery device(s) E1

▶ C7501 Percutaneous breast biopsies using stereotactic guidance, with

placement of breast localization device(s) (eg, clip, metallic pellet),
when performed, and imaging of the biopsy specimen, when
performed, all lesions unilateral and bilateral (for single lesion
biopsy, use appropriate code) E1

▶ C7502 Percutaneous breast biopsies using magnetic resonance guidance,

with placement of breast localization device(s) (eg, clip, metallic
pellet), when performed, and imaging of the biopsy specimen, when
performed, all lesions unilateral or bilateral (for single lesion biopsy,
use appropriate code) E1
▶ C7503 Open biopsy or excision of deep cervical node(s) with intraoperative
identification (eg, mapping) of sentinel lymph node(s) including
injection of non-radioactive dye when performed E1

▶ C7504 Percutaneous vertebroplasties (bone biopsies included when

performed), first cervicothoracic and any additional cervicothoracic
or lumbosacral vertebral bodies, unilateral or bilateral injection,
inclusive of all imaging guidance E1

▶ C7505 Percutaneous vertebroplasties (bone biopsies included when

performed), first lumbosacral and any additional cervicothoracic or
lumbosacral vertebral bodies, unilateral or bilateral injection,
inclusive of all imaging guidance E1

▶ C7506 Arthrodesis, interphalangeal joints, with or without internal fixation

E1
▶ C7507 Percutaneous vertebral augmentations, first thoracic and any
additional thoracic or lumbar vertebral bodies, including cavity
creations (fracture reductions and bone biopsies included when
performed) using mechanical device (eg, kyphoplasty), unilateral or
bilateral cannulations, inclusive of all imaging guidance E1

▶ C7508 Percutaneous vertebral augmentations, first lumbar and any

additional thoracic or lumbar vertebral bodies, including cavity
creations (fracture reductions and bone biopsies included when
performed) using mechanical device (eg, kyphoplasty), unilateral or
bilateral cannulations, inclusive of all imaging guidance E1

▶ C7509 Bronchoscopy, rigid or flexible, diagnostic with cell washing(s)

when performed, with computer-assisted image-guided navigation,
including fluoroscopic guidance when performed E1

▶ C7510 Bronchoscopy, rigid or flexible, with bronchial alveolar lavage(s),

with computer-assisted image-guided navigation, including
fluoroscopic guidance when performed E1

▶ C7511 Bronchoscopy, rigid or flexible, with single or multiple bronchial or

endobronchial biopsy(ies), single or multiple sites, with computer-
assisted image-guided navigation, including fluoroscopic guidance
when performed E1

▶ C7512 Bronchoscopy, rigid or flexible, with single or multiple bronchial or

endobronchial biopsy(ies), single or multiple sites, with
transendoscopic endobronchial ultrasound (EBUS) during
bronchoscopic diagnostic or therapeutic intervention(s) for
peripheral lesion(s), including fluoroscopic guidance when
performed E1
▶ C7513 Dialysis circuit, introduction of needle(s) and/or catheter(s), with
diagnostic angiography of the dialysis circuit, including all direct
puncture(s) and catheter placement(s), injection(s) of contrast, all
necessary imaging from the arterial anastomosis and adjacent artery
through entire venous outflow including the inferior or superior
vena cava, fluoroscopic guidance, with transluminal balloon
angioplasty of central dialysis segment, performed through dialysis
circuit, including all required imaging, radiological supervision and
interpretation, image documentation and report E1

▶ C7514 Dialysis circuit, introduction of needle(s) and/or catheter(s), with

diagnostic angiography of the dialysis circuit, including all direct
puncture(s) and catheter placement(s), injection(s) of contrast, all
necessary imaging from the arterial anastomosis and adjacent artery
through entire venous outflow including the inferior or superior
vena cava, fluoroscopic guidance, with all angioplasty in the central
dialysis segment, and transcatheter placement of intravascular
stent(s), central dialysis segment, performed through dialysis circuit,
including all required imaging, radiological supervision and
interpretation, image documentation and report E1

▶ C7515 Dialysis circuit, introduction of needle(s) and/or catheter(s), with

diagnostic angiography of the dialysis circuit, including all direct
puncture(s) and catheter placement(s), injection(s) of contrast, all
necessary imaging from the arterial anastomosis and adjacent artery
through entire venous outflow including the inferior or superior
vena cava, fluoroscopic guidance, with dialysis circuit permanent
endovascular embolization or occlusion of main circuit or any
accessory veins, including all required imaging, radiological
supervision and interpretation, image documentation and report
E1
▶ C7516 Catheter placement in coronary artery(s) for coronary angiography,
including intraprocedural injection(s) for coronary angiography,
with endoluminal imaging of initial coronary vessel or graft using
intravascular ultrasound (IVUS) or optical coherence tomography
(OCT) during diagnostic evaluation and/or therapeutic intervention
including imaging supervision, interpretation and report E1

▶ C7517 Catheter placement in coronary artery(s) for coronary angiography,

including intraprocedural injection(s) for coronary angiography,
with iliac and/or femoral artery angiography, non-selective, bilateral
or ipsilateral to catheter insertion, performed at the same time as
cardiac catheterization and/or coronary angiography, includes
positioning or placement of the catheter in the distal aorta or
 ipsilateral femoral or iliac artery, injection of dye, production of
permanent images, and radiologic supervision and interpretation
E1
▶ C7518 Catheter placement in coronary artery(ies) for coronary
angiography, including intraprocedural injection(s) for coronary
angiography, imaging supervision and interpretation, with catheter
placement(s) in bypass graft(s) (internal mammary, free arterial,
venous grafts) including intraprocedural injection(s) for bypass graft
angiography with endoluminal imaging of initial coronary vessel or
graft using intravascular ultrasound (IVUS) or optical coherence
tomography (OCT) during diagnostic evaluation and/or therapeutic
intervention including imaging, supervision, interpretation and
report E1

▶ C7519 Catheter placement in coronary artery(ies) for coronary

angiography, including intraprocedural injection(s) for coronary
angiography, imaging supervision and interpretation, with catheter
placement(s) in bypass graft(s) (internal mammary, free arterial,
venous grafts) including intraprocedural injection(s) for bypass graft
angiography with intravascular doppler velocity and/or pressure
derived coronary flow reserve measurement (initial coronary vessel
or graft) during coronary angiography including pharmacologically
induced stress E1

▶ C7520 Catheter placement in coronary artery(ies) for coronary

angiography, including intraprocedural injection(s) for coronary
angiography, imaging supervision and interpretation, with catheter
placement(s) in bypass graft(s) (internal mammary, free arterial,
venous grafts) includes intraprocedural injection(s) for bypass graft
angiography with iliac and/or femoral artery angiography, non-
selective, bilateral or ipsilateral to catheter insertion, performed at
the same time as cardiac catheterization and/or coronary
angiography, includes positioning or placement of the catheter in the
distal aorta or ipsilateral femoral or iliac artery, injection of dye,
production of permanent images, and radiologic supervision and
interpretation E1

▶ C7521 Catheter placement in coronary artery(ies) for coronary

angiography, including intraprocedural injection(s) for coronary
angiography with right heart catheterization with endoluminal
imaging of initial coronary vessel or graft using intravascular
ultrasound (IVUS) or optical coherence tomography (OCT) during
diagnostic evaluation and/or therapeutic intervention including
imaging supervision, interpretation and report E1
▶ C7522 Catheter placement in coronary artery(ies) for coronary
angiography, including intraprocedural injection(s) for coronary
angiography, imaging supervision and interpretation with right heart
catheterization, with intravascular doppler velocity and/or pressure
derived coronary flow reserve measurement (initial coronary vessel
or graft) during coronary angiography including pharmacologically
induced stress E1

▶ C7523 Catheter placement in coronary artery(ies) for coronary

angiography, including intraprocedural injection(s) for coronary
angiography, imaging supervision and interpretation, with left heart
catheterization including intraprocedural injection(s) for left
ventriculography, when performed, with endoluminal imaging of
initial coronary vessel or graft using intravascular ultrasound
(IVUS) or optical coherence tomography (OCT) during diagnostic
evaluation and/or therapeutic intervention including imaging
supervision, interpretation and report E1

▶ C7524 Catheter placement in coronary artery(ies) for coronary

angiography, including intraprocedural injection(s) for coronary
angiography, imaging supervision and interpretation, with left heart
catheterization including intraprocedural injection(s) for left
ventriculography, when performed, with intravascular doppler
velocity and/or pressure derived coronary flow reserve measurement
(initial coronary vessel or graft) during coronary angiography
including pharmacologically induced stress E1

▶ C7525 Catheter placement in coronary artery(ies) for coronary

angiography, including intraprocedural injection(s) for coronary
angiography, imaging supervision and interpretation, with left heart
catheterization including intraprocedural injection(s) for left
ventriculography, when performed, catheter placement(s) in bypass
graft(s) (internal mammary, free arterial, venous grafts) with bypass
graft angiography with endoluminal imaging of initial coronary
vessel or graft using intravascular ultrasound (IVUS) or optical
coherence tomography (OCT) during diagnostic evaluation and/or
therapeutic intervention including imaging supervision,
interpretation and report E1

▶ C7526 Catheter placement in coronary artery(ies) for coronary

angiography, including intraprocedural injection(s) for coronary
angiography, imaging supervision and interpretation, with left heart
catheterization including intraprocedural injection(s) for left
ventriculography, when performed, catheter placement(s) in bypass
 graft(s) (internal mammary, free arterial, venous grafts) with bypass
graft angiography with intravascular doppler velocity and/or
pressure derived coronary flow reserve measurement (initial
coronary vessel or graft) during coronary angiography including
pharmacologically induced stress E1

▶ C7527 Catheter placement in coronary artery(ies) for coronary

angiography, including intraprocedural injection(s) for coronary
angiography, imaging supervision and interpretation, with right and
left heart catheterization including intraprocedural injection(s) for
left ventriculography, when performed, with endoluminal imaging
of initial coronary vessel or graft using intravascular ultrasound
(IVUS) or optical coherence tomography (OCT) during diagnostic
evaluation and/or therapeutic intervention including imaging
supervision, interpretation and report E1

▶ C7528 Catheter placement in coronary artery(ies) for coronary

angiography, including intraprocedural injection(s) for coronary
angiography, imaging supervision and interpretation, with right and
left heart catheterization including intraprocedural injection(s) for
left ventriculography, when performed, with intravascular doppler
velocity and/or pressure derived coronary flow reserve measurement
(initial coronary vessel or graft) during coronary angiography
including pharmacologically induced stress E1

▶ C7529 Catheter placement in coronary artery(ies) for coronary

angiography, including intraprocedural injection(s) for coronary
angiography, imaging supervision and interpretation, with right and
left heart catheterization including intraprocedural injection(s) for
left ventriculography, when performed, catheter placement(s) in
bypass graft(s) (internal mammary, free arterial, venous grafts) with
bypass graft angiography with intravascular doppler velocity and/or
pressure derived coronary flow reserve measurement (initial
coronary vessel or graft) during coronary angiography including
pharmacologically induced stress E1

▶ C7530 Dialysis circuit, introduction of needle(s) and/or catheter(s), with

diagnostic angiography of the dialysis circuit, including all direct
puncture(s) and catheter placement(s), injection(s) of contrast, all
necessary imaging from the arterial anastomosis and adjacent artery
through entire venous outflow including the inferior or superior
vena cava, fluoroscopic guidance, with transluminal balloon
angioplasty, peripheral dialysis segment,