Documents
Resources
Learning Center
Upload
Plans & pricing Sign in
Sign Out
Your Federal Quarterly Tax Payments are due April 15th Get Help Now >>

Procedures excluded from the hospital outpatient surgical fee

VIEWS: 4 PAGES: 5

									Procedures Excluded from the Hospital
Outpatient Surgical Fee Schedule

  The following information is supplemental to the Emergency Services Facility Payment Policy.
                                               ®
  This information applies to Tufts Health Plan outpatient facilities.
  The list below contains procedure codes which are listed within the CPT surgical code range that are not
  included in the Tufts Health Plan Hospital Outpatient Surgical Fee Schedule (HOSFS).

  CPT Procedure Code                Brief Description
         11901                      Intra-lesional injection
         17250                      Chemical cauterization of gran
         17360                      Exfoliation for acne
         17380                      Electrolysis epilation
         20979                      Ultrasound bone stimulation
         29000                      Application of body cast
         29010                      Risser jacket
         29015                      Risser jacket
         29020                      Turnbuckle jacket
         29025                      Turnbuckle jacket
         29035                      Body cast
         29040                      Minerva cast
         29044                      Body cast
         29046                      Body cast
         29049                      App cast figure of eight
         29055                      Shoulder spice
         29058                      Flea cast
         29065                      Long arm cast
         29075                      Short arm cast
         29085                      Gauntlet cast
         29086                      Application of finger cast
         29105                      Splints, upper extremity
         29125                      Splints, upper extremity
         29105                      Splints, upper extremity
         29125                      Splints, upper extremity
         29126                      Apply forearm splint
         29130                      Application of finger splint
         29131                      Application of finger splint
         29200                      Strapping of chest
         29220                      Strapping of low back
         29240                      Strapping of shoulder
         29260                      Strapping of elbow or wrist
         29280                      Strapping of hand or finger
         29305                      Hip spice
         29325                      Hip spice
         29345                      Long leg cast
         29355                      Long leg cast

  This payment policy provides information on Tufts Health Plan claims adjudication processing guidelines. As every claim is unique, the use of this
  policy is not a guarantee of payment nor a final prediction of how specific claim(s) will be adjudicated. Claims payment is subject to Member eligibility
  and benefits on the date of service, coordination of benefits, referral and utilization management guidelines when applicable, adherence to plan policies
  and procedures and claims editing logic. This policy does not apply to Tufts Health Plan Medicare Preferred, Uniformed Services Family Health Plan or
  PHCS network Members. Providers in the New Hampshire service area are subject to CIGNA HealthCare’s provider arrangement for the purpose of
  CareLinkSM Members.

  Originated 11/2004, Revised 05/2008                                   1 of 5           Tufts Health Plan – List of Procedures Excluded from HOSFS
CPT Procedure Code                Brief Description
       29358                      Long leg cast brace
       29365                      Cylinder cast
       29405                      Short leg cast
       29425                      Short leg cast
       29435                      Apply short cast
       29440                      Cast walker
       29445                      Apply rigid leg cast
       29450                      Club foot cast
       29505                      Splints, lower extremity
       29515                      Splints, lower extremity
       29520                      Strapping of hip
       29530                      Strapping of knee
       29540                      Strapping of ankle
       29550                      Strapping of toes
       29580                      Unna boot
       29590                      Application of foot splint
       29700                      Remove cast; gaunt, boot, body
       29705                      Remove cast full arm or leg
       29710                      Remove cast shoulder or hip
       29715                      Remove cast turnbuckle jacket
       29720                      Repair of spice, body, jacket
       29730                      Windowing of cast
       29740                      Wedging of cast
       29750                      Wedge of clubfoot cast
       29799                      Unlisted casting procedure
       30200                      Injection, turbinate
       30210                      Displacement therapy, nose
       30901                      Nasal hemorrhage control
       30903                      Control of nosebleed
       31000                      Sinus lavage
       31002                      Sinus lavage
       31500                      Endotracheal intubation
       36400                      Venipuncture,<3yrs old;fem/jug
       36405                      Venipuncture
       36406                      Establish access to vein
       36410                      Venipuncture,3/>yrs old, dx/tx
       36416                      Capillary blood draw
       36420                      Venipuncture
       36425                      Venipuncture
       36450                      Exchange transfusion
       36455                      Exchange transfusion
       36468                      Injection(s); spider veins
       36469                      Injection(s);spider veins

This payment policy provides information on Tufts Health Plan claims adjudication processing guidelines. As every claim is unique, the use of this
policy is not a guarantee of payment nor a final prediction of how specific claim(s) will be adjudicated. Claims payment is subject to Member eligibility
and benefits on the date of service, coordination of benefits, referral and utilization management guidelines when applicable, adherence to plan policies
and procedures and claims editing logic. This policy does not apply to Tufts Health Plan Medicare Preferred, Uniformed Services Family Health Plan or
PHCS network Members. Providers in the New Hampshire service area are subject to CIGNA HealthCare’s provider arrangement for the purpose of
CareLinkSM Members.

Originated 11/2004, Revised 05/2008                                   2 of 5          Tufts Health Plan – List of Procedures Excluded from HOSFS
CPT Procedure Code                Brief Description
       36470                      Sclerosing solution, vein
       36471                      Sclerosing solution, vein
       36511                      Apheresis wbc
       36512                      Apheresis rbc
       36513                      Apheresis platelets
       36514                      Apheresis plasma
       36515                      Apheresis, adsorp/reinfuse
       36516                      Apheresis, selective
       36522                      Photopheresis
       36591                      Collection of blood implantable
       36600                      Arterial puncture
       36680                      Insert needle, bone cavity
       38792                      Injection procedure for lympha
       50686                      Manometric studies, ureter
       51700                      Bladder irrigation
       51701                      Insert bladder catheter
       51702                      Insert temp bladder catheter
       51703                      Insert bladder cath, complex
       51705                      Cystostomy tube change
       51720                      Bladder instillation
       51725                      Cystometrogram
       51726                      Complex cystometrogram
       51736                      Uroflowmetric evaluation
       51741                      Electro-uroflowmetry, first
       51772                      Urethra pressure profile
       51784                      Anal/urinary muscle study
       51785                      Anal/urinary muscle study
       51792                      Urinary reflex study
       51795                      Urine voiding pressure study
       51797                      Intraabdominal pressure test
       51798                      Us urine capacity measure
       54235                      Penile injection
       54240                      Penis pressure study
       54250                      Test penile erection/rigid
       55870                      Electroejaculation
       55875                      Transperineal placement of needles
       57150                      Irrigation, vagina
       57155                      Insertion of uterine tandems/v
       57170                      Diaphragm fitting
       59020                      Fetal oxytocin stress test
       59025                      Fetal non-stress test
       59400                      Obstetrical care
       59409                      Obstetrical delivery

This payment policy provides information on Tufts Health Plan claims adjudication processing guidelines. As every claim is unique, the use of this
policy is not a guarantee of payment nor a final prediction of how specific claim(s) will be adjudicated. Claims payment is subject to Member eligibility
and benefits on the date of service, coordination of benefits, referral and utilization management guidelines when applicable, adherence to plan policies
and procedures and claims editing logic. This policy does not apply to Tufts Health Plan Medicare Preferred, Uniformed Services Family Health Plan or
PHCS network Members. Providers in the New Hampshire service area are subject to CIGNA HealthCare’s provider arrangement for the purpose of
CareLinkSM Members.

Originated 11/2004, Revised 05/2008                                   3 of 5          Tufts Health Plan – List of Procedures Excluded from HOSFS
CPT Procedure Code                Brief Description
       59410                      Obstetrical delivery
       59412                      Antepartum manipulation
       59414                      Deliver placenta
       59425                      Antepartum care only
       59426                      Antepartum care only
       62148                      Retr bone flap t ofix skull
       64400                      Somatic nerve block
       64402                      Somatic nerve block
       64405                      Somatic nerve block
       64413                      Injection for nerve block
       64416                      N block cont infuse, b plex
       64418                      Injection for nerve block
       64445                      Somatic nerve block
       64550                      Apply neurostimulator
       67221                      Ocular photodynamic ther
       67225                      Ocular photodynamic therapy
       67505                      Injection, orbit
       68200                      Injection, subconjunctiva
       90399                      Unlisted immune globulin
       90899                      Unlisted psychiatric procedure
       90999                      Unlisted dialysis
       91010                      Esophageal motility study
       91065                      Breath hydrogen test
       92019                      Eye examination
       92499                      Unlisted ophth proc
       92960                      Cardioversion, elective electr
       93600                      Right heart catheterization
       93602                      Intra-atrial recording
       93603                      Right ventricular recording
       93615                      Esophageal recording
       93616                      Esophageal recording
       93642                      Electrophysiology evaluation
       93650                      Ablate heart dysrhythm focus
       93651                      Ablate heart dysrhythm focus
       93652                      Ablate heart dysrhythm focus
       93741                      Cardiac pacing device analysis
       93742                      Cardic pacing device analysis
       93743                      Cardic pacing device analysis
       93744                      Cardiac pacing device analysis
                                  Initial set-up and programming by a physician of wearable cardioverter-
            93745
                                  defibrillator
            93799                 Unlisted ecg proc
            94799                 Unlisted pulmonary proc
            95199                 Unlisted allergy/immun proc
This payment policy provides information on Tufts Health Plan claims adjudication processing guidelines. As every claim is unique, the use of this
policy is not a guarantee of payment nor a final prediction of how specific claim(s) will be adjudicated. Claims payment is subject to Member eligibility
and benefits on the date of service, coordination of benefits, referral and utilization management guidelines when applicable, adherence to plan policies
and procedures and claims editing logic. This policy does not apply to Tufts Health Plan Medicare Preferred, Uniformed Services Family Health Plan or
PHCS network Members. Providers in the New Hampshire service area are subject to CIGNA HealthCare’s provider arrangement for the purpose of
CareLinkSM Members.

Originated 11/2004, Revised 05/2008                                   4 of 5          Tufts Health Plan – List of Procedures Excluded from HOSFS
CPT Procedure Code                Brief Description
       96570                      Photodynamic therapy
       96571                      Photodynamic therapy
       96999                      Unlisted dermatological proc
       97602                      Wound care non-selective
       97605                      Negative pressure wound therapy
       97606                      Total wound(s) surface area greater than 50 square centimeters
       G0260                      Injection procedure for sacroiliac joint; provision of anesthetic
       G0339                      Image-guided robotic linear accelerator
       G0340                      Image-guided robotic linear accelerator-based stereotactic radiosurgery




This payment policy provides information on Tufts Health Plan claims adjudication processing guidelines. As every claim is unique, the use of this
policy is not a guarantee of payment nor a final prediction of how specific claim(s) will be adjudicated. Claims payment is subject to Member eligibility
and benefits on the date of service, coordination of benefits, referral and utilization management guidelines when applicable, adherence to plan policies
and procedures and claims editing logic. This policy does not apply to Tufts Health Plan Medicare Preferred, Uniformed Services Family Health Plan or
PHCS network Members. Providers in the New Hampshire service area are subject to CIGNA HealthCare’s provider arrangement for the purpose of
CareLinkSM Members.

Originated 11/2004, Revised 05/2008                                   5 of 5          Tufts Health Plan – List of Procedures Excluded from HOSFS

								
To top