Modifier and HCPCS Changes for January 2025 - JF Part B
Modifier and HCPCS Changes for January 2025
The following new and deleted National Level II modifiers and Healthcare Common Procedure Coding System (HCPCS) are effective for dates of service on/after January 1, 2025.
In compliance with the Health Insurance Portability and Accountability Act (HIPAA), CMS eliminated the 3-month grace period for discontinued codes in Change Request (CR) 3093 dated February 6, 2004. Effective for dates of services on/after January 1, 2010, there is no grace period for billing discontinued HCPCS codes.
Note: The inclusion of modifiers or codes on this web page do not necessarily indicate coverage. New modifiers and HCPCS identified as Durable Medical Equipment (DME) are not included in this listing.
New Modifiers
There are no new modifiers being implemented.
New Codes
| HCPCS | DESCRIPTION |
|---|---|
| A9615 | Injection, pegulicianine, 1 mg |
| C1735 | Catheter(s), intravascular for renal denervation, radiofrequency, including all single use system components |
| C1736 | Catheter(s), intravascular for renal denervation, ultrasound, including all single use system components |
| C1737 | Joint fusion and fixation device(s), sacroiliac and pelvis, including all system components (implantable) |
| C1738 | Powered, single-use (i.e. disposable) endoscopic ultrasound-guided biopsy device |
| C1739 | Tissue marker, imaging and non-imaging device (implantable) |
| C7562 | Catheter placement in coronary artery(s) 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 intraprocedural coronary fractional flow reserve (ffr) with 3d functional mapping of color-coded ffr values for the coronary tree, derived from coronary angiogram data, for real-time review and interpretation of possible atherosclerotic stenosis(es) intervention |
| C7563 | Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, initial artery and all additional arteries |
| C7564 | Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance with intravascular ultrasound (noncoronary vessel(s)) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation |
| C7565 | Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), recurrent, including implantation of mesh or other prosthesis when performed, total length of defect(s) less than 3 cm, reducible with removal of total or near total non-infected mesh or other prosthesis at the time of initial or recurrent anterior abdominal hernia repair or parastomal hernia repair |
| C8001 | 3d anatomical segmentation imaging for preoperative planning, data preparation and transmission, obtained from previous diagnostic computed tomographic or magnetic resonance examination of the same anatomy |
| C8002 | Preparation of skin cell suspension autograft, automated, including all enzymatic processing and device components (do not report with manual suspension preparation) |
| C8003 | Implantation of medial knee extraarticular implantable shock absorber spanning the knee joint from distal femur to proximal tibia, open, includes measurements, positioning and adjustments, with imaging guidance (eg, fluoroscopy) |
| C9173 | Injection, filgrastim-txid (nypozi), biosimilar, 1 microgram |
| C9610 | Catheter, transluminal drug delivery with or without angioplasty, coronary, non-laser (insertable) |
| C9804 | Elastomeric infusion pump (e.g., on-q* pump with bolus), including catheter and all disposable system components, non-opioid medical device (must be a qualifying medicare non-opioid medical device for post-surgical pain relief in accordance with section 4135 of the caa, 2023) |
| C9806 | Rotary peristaltic infusion pump (e.g., ambit pump), including catheter and all disposable system components, non-opioid medical device (must be a qualifying medicare non-opioid medical device for post-surgical pain relief in accordance with section 4135 of the caa, 2023) |
| C9807 | Nerve stimulator, percutaneous, peripheral (e.g., sprint peripheral nerve stimulation system), including electrode and all disposable system components, non-opioid medical device (must be a qualifying medicare non-opioid medical device for post-surgical pain relief in accordance with section 4135 of the caa, 2023) |
| C9808 | Nerve cryoablation probe (e.g., cryoice, cryosphere, cryosphere max, cryoice cryosphere, cryoice cryo2), including probe and all disposable system components, non-opioid medical device (must be a qualifying medicare non-opioid medical device for post-surgical pain relief in accordance with section 4135 of the caa, 2023) |
| C9809 | Cryoablation needle (e.g., iovera system), including needle/tip and all disposable system components, non-opioid medical device (must be a qualifying medicare non-opioid medical device for post-surgical pain relief in accordance with section 4135 of the caa, 2023) |
| D2956 | Removal of an indirect restoration on a natural tooth |
| D6180 | Implant maintenance procedures when a full arch fixed hybrid prosthesis is not removed, including cleansing of prosthesis and abutments |
| D6193 | Replacement of an implant screw |
| D7252 | Partial extraction for immediate implant placement |
| D7259 | Nerve dissection |
| D8091 | Comprehensive orthodontic treatment with orthognathic surgery |
| D8671 | Periodic orthodontic treatment visit associated with orthognathic surgery |
| D9913 | Administration of neuromodulators |
| D9914 | Administration of dermal fillers |
| D9959 | Unspecified sleep apnea services procedure, by report |
| G0532 | Take-home supply of nasal nalmefene hydrochloride; one carton of two, 2.7 mg per 0.1 ml nasal sprays (provision of the services by a medicare-enrolled opioid treatment program);( list separately in addition to each primary code) |
| G0533 | Medication assisted treatment, buprenorphine (injectable) administered on a weekly basis; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a medicare-enrolled opioid treatment program) |
| G0534 | Coordinated care and/or referral services, such as to adequate and accessible community resources to address unmet health-related social needs, including harm reduction interventions and recovery support services a patient needs and wishes to pursue, which significantly limit the ability to diagnose or treat an opioid use disorder; each additional 30 minutes of services (provision of the services by a medicare-enrolled opioid treatment program); (list separately in addition to each primary code) |
| G0535 | Patient navigational services, provided directly or by referral; including helping the patient to navigate health systems and identify care providers and supportive services, to build patient self-advocacy and communication skills with care providers, and to promote patient-driven action plans and goals; each additional 30 minutes of services (provision of the services by a medicare-enrolled opioid treatment program); (list separately in addition to each primary code) |
| G0536 | Peer recovery support services, provided directly or by referral; including leveraging knowledge of the condition or lived experience to provide support, mentorship, or inspiration to meet oud treatment and recovery goals; conducting a person-centered interview to understand the patient's life story, strengths, needs, goals, preferences, and desired outcomes; developing and proposing strategies to help meet person-centered treatment goals; assisting the patient in locating or navigating recovery support services; each additional 30 minutes of services (provision of the services by a medicare-enrolled opioid treatment program); (list separately in addition to each primary code) |
| G0537 | Administration of a standardized, evidence-based atherosclerotic cardiovascular disease (ascvd) risk assessment, 5-15 minutes, not more often than every 12 months |
| G0538 | Atherosclerotic cardiovascular disease (ascvd) risk management services; clinical staff time; per calendar month |
| G0539 | Caregiver training in behavior management/modification for caregiver(s) of patients with a mental or physical health diagnosis, administered by physician or other qualified health care professional (without the patient present), face-to-face; initial 30 minutes |
| G0540 | Caregiver training in behavior management/modification for parent(s)/guardian(s)/caregiver(s) of patients with a mental or physical health diagnosis, administered by physician or other qualified health care professional (without the patient present), face-to-face; each additional 15 minutes |
| G0541 | Caregiver training in direct care strategies and techniques to support care for patients with an ongoing condition or illness and to reduce complications (including, but not limited to, techniques to prevent decubitus ulcer formation, wound care, and infection control) (without the patient present), face-to-face; initial 30 minutes |
| G0542 | Caregiver training in direct care strategies and techniques to support care for patients with an ongoing condition or illness and to reduce complications (including, but not limited to, techniques to prevent decubitus ulcer formation, wound care, and infection control) (without the patient present), face-to-face; each additional 15 minutes (list separately in addition to code for primary service) (use g0542 in conjunction with g0541) |
| G0543 | Group caregiver training in direct care strategies and techniques to support care for patients with an ongoing condition or illness and to reduce complications (including, but not limited to, techniques to prevent decubitus ulcer formation, wound care, and infection control) (without the patient present), face-to-face with multiple sets of caregivers |
| G0544 | Post discharge telephonic follow-up contacts performed in conjunction with a discharge from the emergency department for behavioral health or other crisis encounter, 4 calls per calendar month |
| G0545 | Visit complexity inherent to hospital inpatient or observation care associated with a confirmed or suspected infectious disease by an infectious diseases specialist, including disease transmission risk assessment and mitigation, public health investigation, analysis, and testing, and complex antimicrobial therapy counseling and treatment (add-on code, list separately in addition to hospital inpatient or observation evaluation and management visit, initial, same day discharge, subsequent or discharge) |
| G0546 | Interprofessional telephone/internet/electronic health record assessment and management service provided by a practitioner in a specialty whose covered services are limited by statute to services for the diagnosis and treatment of mental illness, including a verbal and written report to the patient's treating/requesting practitioner; 5-10 minutes of medical consultative discussion and review |
| G0547 | Interprofessional telephone/internet/electronic health record assessment and management service provided by a practitioner in a specialty whose covered services are limited by statute to services for the diagnosis and treatment of mental illness, including a verbal and written report to the patient's treating/requesting practitioner; 11-20 minutes of medical consultative discussion and review |
| G0548 | Interprofessional telephone/internet/electronic health record assessment and management service provided by a practitioner in a specialty whose covered services are limited by statute to services for the diagnosis and treatment of mental illness, including a verbal and written report to the patient's treating/requesting practitioner; 21-30 minutes of medical consultative discussion and review |
| G0549 | Interprofessional telephone/internet/electronic health record assessment and management service provided by a practitioner in a specialty whose covered services are limited by statute to services for the diagnosis and treatment of mental illness, including a verbal and written report to the patient's treating/requesting practitioner; 31 or more minutes of medical consultative discussion and review |
| G0550 | Interprofessional telephone/internet/electronic health record assessment and management service provided by a practitioner in a specialty whose covered services are limited by statute to services for the diagnosis and treatment of mental illness, including a written report to the patient's treating/requesting practitioner, 5 minutes or more of medical consultative time |
| G0551 | Interprofessional telephone/internet/electronic health record referral service(s) provided by a treating/requesting practitioner in a specialty whose covered services are limited by statute to services for the diagnosis and treatment of mental illness, 30 minutes |
| G0552 | Supply of digital mental health treatment device and initial education and onboarding, per course of treatment that augments a behavioral therapy plan |
| G0553 | First 20 minutes of monthly treatment management services directly related to the patient's therapeutic use of the digital mental health treatment (dmht) device that augments a behavioral therapy plan, physician/other qualified health care professional time reviewing information related to the use of the dmht device, including patient observations and patient specific inputs in a calendar month and requiring at least one interactive communication with the patient/caregiver during the calendar month |
| G0554 | Each additional 20 minutes of monthly treatment management services directly related to the patient's therapeutic use of the digital mental health treatment (dmht) device that augments a behavioral therapy plan, physician/other qualified health care professional time reviewing data generated from the dmht device from patient observations and patient specific inputs in a calendar month and requiring at least one interactive communication with the patient/caregiver during the calendar month |
| G0555 | Provision of replacement patient electronics system (e.g., system pillow, handheld reader) for home pulmonary artery pressure monitoring |
| G0556 | Advanced primary care management services for a patient with one chronic condition [expected to last at least 12 months, or until the death of the patient, which place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline], or fewer, provided by clinical staff and directed by a physician or other qualified health care professional who is responsible for all primary care and serves as the continuing focal point for all needed health care services, per calendar month, with the following elements, as appropriate: consent; ++ inform the patient of the availability of the service; that only one practitioner can furnish and be paid for the service during a calendar month; of the right to stop the services at any time (effective at the end of the calendar month); and that cost sharing may apply. ++ document in patient's medical record that consent was obtained. initiation during a qualifying visit for new patients or patients not seen within 3 years; provide 24/7 access for urgent needs to care team/practitioner, including providing patients/caregivers with a way to contact health care professionals in the practice to discuss urgent needs regardless of the time of day or day of week; continuity of care with a designated member of the care team with whom the patient is able to schedule successive routine appointments; deliver care in alternative ways to traditional office visits to best meet the patient's needs, such as home visits and/or expanded hours; overall comprehensive care management; ++ systematic needs assessment (medical and psychosocial). ++ system-based approaches to ensure receipt of preventive services. ++ medication reconciliation, management and oversight of self-management. development, implementation, revision, and maintenance of an electronic patient-centered comprehensive care plan with typical care plan elements when clinically relevant; ++ care plan is available timely within and outside the billing practice as appropriate to individuals involved in the beneficiary's care, can be routinely accessed and updated by care team/practitioner, and copy of care plan to patient/caregiver; coordination of care transitions between and among health care providers and settings, including referrals to other clinicians and follow-up after an emergency department visit and discharges from hospitals, skilled nursing facilities or other health care facilities as applicable; ++ ensure timely exchange of electronic health information with other practitioners and providers to support continuity of care. ++ ensure timely follow-up communication (direct contact, telephone, electronic) with the patient and/or caregiver after an emergency department visit and discharges from hospitals, skilled nursing facilities, or other health care facilities, within 7 calendar days of discharge, as clinically indicated. ongoing communication and coordinating receipt of needed services from practitioners, home- and community-based service providers, community-based social service providers, hospitals, and skilled nursing facilities (or other health care facilities), and document communication regarding the patient's psychosocial strengths and needs, functional deficits, goals, preferences, and desired outcomes, including cultural and linguistic factors, in the patient's medical record; enhanced opportunities for the beneficiary and any caregiver to communicate with the care team/practitioner regarding the beneficiary's care through the use of asynchronous non-face-to-face consultation methods other than telephone, such as secure messaging, email, internet, or patient portal, and other communication-technology based services, including remote evaluation of pre-recorded patient information and interprofessional telephone/internet/ehr referral service(s), to maintain ongoing communication with patients, as appropriate; ++ ensure access to patient-initiated digital communications that require a clinical decision, such as virtual check-ins and digital online assessment and management and e/m visits (or e-visits). analyze patient population data to identify gaps in care and offer additional interventions, as appropriate; risk stratify the practice population based on defined diagnoses, claims, or other electronic data to identify and target services to patients; be assessed through performance measurement of primary care quality, total cost of care, and meaningful use of certified ehr technology |
| G0557 | Advanced primary care management services for a patient with multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, which place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, provided by clinical staff and directed by a physician or other qualified health care professional who is responsible for all primary care and serves as the continuing focal point for all needed health care services, per calendar month, with the following elements, as appropriate: consent; ++ inform the patient of the availability of the service; that only one practitioner can furnish and be paid for the service during a calendar month; of the right to stop the services at any time (effective at the end of the calendar month); and that cost sharing may apply. ++ document in patient's medical record that consent was obtained. initiation during a qualifying visit for new patients or patients not seen within 3 years; provide 24/7 access for urgent needs to care team/practitioner, including providing patients/caregivers with a way to contact health care professionals in the practice to discuss urgent needs regardless of the time of day or day of week; continuity of care with a designated member of the care team with whom the patient is able to schedule successive routine appointments; deliver care in alternative ways to traditional office visits to best meet the patient's needs, such as home visits and/or expanded hours; overall comprehensive care management; ++ systematic needs assessment (medical and psychosocial). ++ system-based approaches to ensure receipt of preventive services. ++ medication reconciliation, management and oversight of self-management. development, implementation, revision, and maintenance of an electronic patient-centered comprehensive care plan; ++ care plan is available timely within and outside the billing practice as appropriate to individuals involved in the beneficiary's care, can be routinely accessed and updated by care team/practitioner, and copy of care plan to patient/caregiver; coordination of care transitions between and among health care providers and settings, including referrals to other clinicians and follow-up after an emergency department visit and discharges from hospitals, skilled nursing facilities or other health care facilities as applicable; ++ ensure timely exchange of electronic health information with other practitioners and providers to support continuity of care. ++ ensure timely follow-up communication (direct contact, telephone, electronic) with the patient and/or caregiver after an emergency department visit and discharges from hospitals, skilled nursing facilities, or other health care facilities, within 7 calendar days of discharge, as clinically indicated. ongoing communication and coordinating receipt of needed services from practitioners, home- and community-based service providers, community-based social service providers, hospitals, and skilled nursing facilities (or other health care facilities), and document communication regarding the patient's psychosocial strengths and needs, functional deficits, goals, preferences, and desired outcomes, including cultural and linguistic factors, in the patient's medical record; enhanced opportunities for the beneficiary and any caregiver to communicate with the care team/practitioner regarding the beneficiary's care through the use of asynchronous non-face-to-face consultation methods other than telephone, such as secure messaging, email, internet, or patient portal, and other communication-technology based services, including remote evaluation of pre-recorded patient information and interprofessional telephone/internet/ehr referral service(s), to maintain ongoing communication with patients, as appropriate; ++ ensure access to patient-initiated digital communications that require a clinical decision, such as virtual check-ins and digital online assessment and management and e/m visits (or e-visits). analyze patient population data to identify gaps in care and offer additional interventions, as appropriate; risk stratify the practice population based on defined diagnoses, claims, or other electronic data to identify and target services to patients; be assessed through performance measurement of primary care quality, total cost of care, and meaningful use of certified ehr technology |
| G0558 | Advanced primary care management services for a patient that is a qualified medicare beneficiary with multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, which place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, provided by clinical staff and directed by a physician or other qualified health care professional who is responsible for all primary care and serves as the continuing focal point for all needed health care services, per calendar month, with the following elements, as appropriate: consent; ++ inform the patient of the availability of the service; that only one practitioner can furnish and be paid for the service during a calendar month; of the right to stop the services at any time (effective at the end of the calendar month); and that cost sharing may apply. ++ document in patient's medical record that consent was obtained. initiation during a qualifying visit for new patients or patients not seen within 3 years; provide 24/7 access for urgent needs to care team/practitioner, including providing patients/caregivers with a way to contact health care professionals in the practice to discuss urgent needs regardless of the time of day or day of week; continuity of care with a designated member of the care team with whom the patient is able to schedule successive routine appointments; deliver care in alternative ways to traditional office visits to best meet the patient's needs, such as home visits and/or expanded hours; overall comprehensive care management; ++ systematic needs assessment (medical and psychosocial). ++ system-based approaches to ensure receipt of preventive services. ++ medication reconciliation, management and oversight of self-management. development, implementation, revision, and maintenance of an electronic patient-centered comprehensive care plan; ++ care plan is available timely within and outside the billing practice as appropriate to individuals involved in the beneficiary's care, can be routinely accessed and updated by care team/practitioner, and copy of care plan to patient/caregiver; coordination of care transitions between and among health care providers and settings, including referrals to other clinicians and follow-up after an emergency department visit and discharges from hospitals, skilled nursing facilities or other health care facilities as applicable; ++ ensure timely exchange of electronic health information with other practitioners and providers to support continuity of care. ++ ensure timely follow-up communication (direct contact, telephone, electronic) with the patient and/or caregiver after an emergency department visit and discharges from hospitals, skilled nursing facilities, or other health care facilities, within 7 calendar days of discharge, as clinically indicated. ongoing communication and coordinating receipt of needed services from practitioners, home- and community-based service providers, community-based social service providers, hospitals, and skilled nursing facilities (or other health care facilities), and document communication regarding the patient's psychosocial strengths and needs, functional deficits, goals, preferences, and desired outcomes, including cultural and linguistic factors, in the patient's medical record; enhanced opportunities for the beneficiary and any caregiver to communicate with the care team/practitioner regarding the beneficiary's care through the use of asynchronous non-face-to-face consultation methods other than telephone, such as secure messaging, email, internet, or patient portal, and other communication-technology based services, including remote evaluation of pre-recorded patient information and interprofessional telephone/internet/ehr referral service(s), to maintain ongoing communication with patients, as appropriate; ++ ensure access to patient-initiated digital communications that require a clinical decision, such as virtual check-ins and digital online assessment and management and e/m visits (or e-visits). analyze patient population data to identify gaps in care and offer additional interventions, as appropriate; risk stratify the practice population based on defined diagnoses, claims, or other electronic data to identify and target services to patients; be assessed through performance measurement of primary care quality, total cost of care, and meaningful use of certified ehr technology |
| G0559 | Post-operative follow-up visit complexity inherent to evaluation and management services addressing surgical procedure(s), provided by a physician or qualified health care professional who is not the practitioner who performed the procedure (or in the same group practice) and is of the same or of a different specialty than the practitioner who performed the procedure, within the 90-day global period of the procedure(s), once per 90-day global period, when there has not been a formal transfer of care and requires the following required elements, when possible and applicable: reading available surgical note to understand the relative success of the procedure, the anatomy that was affected, and potential complications that could have arisen due to the unique circumstances of the patient's operation. research the procedure to determine expected post-operative course and potential complications (in the case of doing a post-op for a procedure outside the specialty). evaluate and physically examine the patient to determine whether the post-operative course is progressing appropriately. communicate with the practitioner who performed the procedure if any questions or concerns arise. (list separately in addition to office/outpatient evaluation and management visit, new or established) |
| G0560 | Safety planning interventions, each 20 minutes personally performed by the billing practitioner, including assisting the patient in the identification of the following personalized elements of a safety plan: recognizing warning signs of an impending suicidal or substance use-related crisis; employing internal coping strategies; utilizing social contacts and social settings as a means of distraction from suicidal thoughts or risky substance use; utilizing family members, significant others, caregivers, and/or friends to help resolve the crisis; contacting mental health or substance use disorder professionals or agencies; and making the environment safe |
| G0561 | Tympanostomy with local or topical anesthesia and insertion of a ventilating tube when performed with tympanostomy tube delivery device, unilateral (list separately in addition to 69433) (do not use in conjunction with 0583t) |
| G0562 | Therapeutic radiology simulation-aided field setting; complex, including acquisition of pet and ct imaging data required for radiopharmaceutical-directed radiation therapy treatment planning (i.e., modeling) |
| G0563 | Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance and real-time positron emissions-based delivery adjustments to 1 or more lesions, entire course not to exceed 5 fractions |
| G0564 | Creation of subcutaneous pocket with insertion of 365 day implantable interstitial glucose sensor, including system activation and patient training |
| G0565 | Removal of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic site and insertion of new 365 day implantable sensor, including system activation |
| H0052 | Missing and murdered indigenous persons (mmip) mental health and clinical care |
| H0053 | Historical trauma (ht) mental health and clinical care for indigenous persons |
| J0139 | Injection, adalimumab, 1 mg |
| J0601 | Sevelamer carbonate (renvela or therapeutically equivalent), oral, 20 mg (for esrd on dialysis) |
| J0602 | Sevelamer carbonate (renvela or therapeutically equivalent), oral, powder, 20 mg (for esrd on dialysis) |
| J0603 | Sevelamer hydrochloride (renagel or therapeutically equivalent), oral, 20 mg (for esrd on dialysis) |
| J0605 | Sucroferric oxyhydroxide, oral, 5 mg (for esrd on dialysis) |
| J0607 | Lanthanum carbonate, oral, 5 mg (for esrd on dialysis) |
| J0608 | Lanthanum carbonate, oral, powder, 5 mg, not therapeutically equivalent to j0607 (for esrd on dialysis) |
| J0609 | Ferric citrate, oral, 3 mg ferric iron, (for esrd on dialysis) |
| J0615 | Calcium acetate, oral, 23 mg (for esrd on dialysis) |
| J0666 | Injection, bupivacaine liposome, 1 mg |
| J0870 | Injection, imetelstat, 1 mg |
| J0901 | Vadadustat, oral, 1 mg (for esrd on dialysis) |
| J1307 | Injection, crovalimab-akkz, 10 mg |
| J1414 | Injection, fidanacogene elaparvovec-dzkt, per therapeutic dose |
| J1552 | Injection, immune globulin (alyglo), 500 mg |
| J2290 | Injection, nafcillin sodium, 20 mg |
| J2472 | Injection, pantoprazole sodium in sodium chloride (baxter), 40 mg |
| J2802 | Injection, romiplostim, 1 microgram |
| J3392 | Injection, exagamglogene autotemcel, per treatment |
| J7514 | Mycophenolate mofetil (myhibbin), oral suspension, 100 mg |
| J7601 | Ensifentrine, inhalation suspension, fda approved final product, non-compounded, administered through dme, unit dose form, 3 mg |
| J9026 | Injection, tarlatamab-dlle, 1 mg |
| J9028 | Injection, nogapendekin alfa inbakicept-pmln, for intravesical use, 1 microgram |
| J9076 | Injection, cyclophosphamide (baxter), 5 mg |
| J9292 | Injection, pemetrexed (avyxa), not therapeutically equivalent to j9305, 10 mg |
| M1371 | Most recent glycemic status assessment (hba1c or gmi) level < 7.0% |
| M1372 | Most recent glycemic status assessment (hba1c or gmi) level >= 7.0% and < 8.0% |
| M1373 | Most recent glycemic status assessment (hba1c or gmi) level >= 8.0% and <= 9.0% |
| M1374 | An additional encounter with an ra diagnosis during the performance period or prior performance period that is at least 90 days before or after an encounter with an ra diagnosis during the performance period |
| M1375 | An additional encounter with an ra diagnosis during the performance period or prior performance period that is at least 90 days before or after an encounter with an ra diagnosis during the performance period |
| M1376 | An additional encounter with an ra diagnosis during the performance period or prior performance period that is at least 90 days before or after an encounter with an ra diagnosis during the performance period |
| M1377 | Recommended follow-up interval for repeat colonoscopy of 10 years documented in colonoscopy report and communicated with patient |
| M1378 | Documentation of medical reason(s) for not recommending a 10 year follow-up interval (e.g., inadequate prep, familial or personal history of colonic polyps, patient had no adenoma and age is >= 66 years old, or life expectancy < 10 years, other medical reasons) |
| M1379 | A 10 year follow-up interval for colonoscopy not recommended, reason not otherwise specified |
| M1380 | Filled at least two prescriptions during the performance period for any combination of the qualifying oral antipsychotic medications listed under "denominator note" or the long-acting injectable antipsychotic medications listed under "denominator note" |
| M1381 | Patients with secondary stroke (e.g., a subsequent stroke that may occur with vasospasm in the setting of subarachnoid hemorrhage) within 5 days of the initial procedure |
| M1382 | Patient encounter during the performance period with place of service code 11 |
| M1383 | Acute pvd |
| M1384 | Patients who died during the performance period |
| M1385 | Documentation of patient reasons for patients who were not seen for the second pam survey (e.g., less than four months between baseline pam assessment and follow-up |
| M1386 | Patients with an excisional surgery for melanoma or melanoma in situ in the past 5 years with an initial ajcc staging of 0, i, or ii at the start of the performance period |
| M1387 | Patients who died during the performance period |
| M1388 | Patients with documentation of an exam performed for recurrence of melanoma |
| M1390 | Patients who do not have a documented exam performed for recurrence of melanoma or no documentation within the performance period |
| M1391 | All patients who were diagnosed with recurrent melanoma during the current performance period |
| M1392 | Documentation of patient reasons for no examination, i.e., refusal of examination or lost to follow-up (documentation must include information that the clinician was unable to reach the patient by phone, mail or secure electronic mail - at least one method must be documented) |
| M1393 | Patients who were not diagnosed with recurrent melanoma during the current performance period |
| M1394 | Stages i-iii breast cancer |
| M1395 | Patients receiving an initial chemotherapy regimen with a defined duration with the eligible clinician or group |
| M1396 | Patients on a therapeutic clinical trial |
| M1397 | Patients with recurrence/disease progression |
| M1398 | Patients with baseline and follow-up promis surveys documented in the medical record |
| M1399 | Patients who leave the practice during the follow-up period |
| M1400 | Patients who died during the follow-up period |
| M1401 | Stages i-iii breast cancer |
| M1402 | Patients receiving an initial chemotherapy regimen with a defined duration with the eligible clinician or group |
| M1403 | Patients with baseline and follow-up promis surveys documented in the medical record |
| M1404 | Patients on a therapeutic clinical trial |
| M1405 | Patients with recurrence/disease progression |
| M1406 | Patients who leave the practice during the follow-up period |
| M1407 | Patients who died during the follow-up period |
| M1408 | Patients who have germline brca testing completed before diagnosis of epithelial ovarian, fallopian tube, or primary peritoneal cancer |
| M1409 | Patients who received germline testing for brca1 and brca2 or genetic counseling completed within 6 months of diagnosis |
| M1410 | Patients who did not have germline testing for brca1 and brca2 or genetic counseling completed within 6 months of diagnosis |
| M1411 | Currently on first-line immune checkpoint inhibitors without chemotherapy |
| M1412 | Patients with metastatic nsclc with epidermal growth factor receptor (egfr) mutations, alk genomic tumor aberrations, or other targetable genomic abnormalities with approved first-line targeted therapy, such as nsclc with ros1 rearrangement, braf v600e mutation, ntrk 1/2/3 gene fusion, met ex14 skipping mutation, and ret rearrangement |
| M1413 | Patients who had a positive pd-l1 biomarker expression test result prior to the initiation of first-line immune checkpoint inhibitor therapy |
| M1414 | Documentation of medical reason(s) for not performing the pd-l1 biomarker expression test prior to initiation of first-line immune checkpoint inhibitor therapy (e.g., patient is in an urgent or emergent situation where delay of treatment would jeopardize the patient's health status; other medical reasons/contraindication) |
| M1415 | Patients who did not have a positive pd-l1 biomarker expression test result prior to the initiation of first-line immune checkpoint inhibitor therapy |
| M1416 | Patient received hospice services any time during the performance period |
| M1417 | Patients who are up to date on their covid-19 vaccinations as defined by cdc recommendations on current vaccination |
| M1418 | Patients who are not up to date on their covid-19 vaccinations as defined by cdc recommendations on current vaccination because of a medical contraindication documented by clinician |
| M1419 | Patients who are not up to date on their covid-19 vaccinations as defined by cdc recommendations on current vaccination |
| M1420 | Complete ophthalmologic care mips value pathway |
| M1421 | Dermatological care mips value pathway |
| M1422 | Gastroenterology care mips value pathway |
| M1423 | Optimal care for patients with urologic conditions mips value pathway |
| M1424 | Pulmonology care mips value pathway |
| M1425 | Surgical care mips value pathway |
| Q0155 | Dronabinol (syndros), 0.1 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen |
| Q0521 | Pharmacy supplying fee for hiv pre-exposure prophylaxis fda approved prescription |
| Q4346 | Shelter dm matrix, per square centimeter |
| Q4347 | Rampart dl matrix, per square centimeter |
| Q4348 | Sentry sl matrix, per square centimeter |
| Q4349 | Mantle dl matrix, per square centimeter |
| Q4350 | Palisade dm matrix, per square centimeter |
| Q4351 | Enclose tl matrix, per square centimeter |
| Q4352 | Overlay sl matrix, per square centimeter |
| Q4353 | Xceed tl matrix, per square centimeter |
| Q5139 | Injection, eculizumab-aeeb (bkemv), biosimilar, 10 mg |
| Q5140 | Injection, adalimumab-fkjp, biosimilar, 1 mg |
| Q5141 | Injection, adalimumab-aaty, biosimilar, 1 mg |
| Q5142 | Injection, adalimumab-ryvk biosimilar, 1 mg |
| Q5143 | Injection, adalimumab-adbm, biosimilar, 1 mg |
| Q5144 | Injection, adalimumab-aacf (idacio), biosimilar, 1 mg |
| Q5145 | Injection, adalimumab-afzb (abrilada), biosimilar, 1 mg |
| Q5146 | Injection, trastuzumab-strf (hercessi), biosimilar, 10 mg |
| Q9996 | Injection, ustekinumab-ttwe (pyzchiva), subcutaneous, 1 mg |
| Q9997 | Injection, ustekinumab-ttwe (pyzchiva), intravenous, 1 mg |
| Q9998 | Injection, ustekinumab-aekn (selarsdi), 1 mg |
Deleted Codes
| HCPCS | DESCRIPTION |
|---|---|
| C7558 | Catheter placement in coronary artery(s) 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 pharmacologic agent administration (eg, inhaled nitric oxide, intravenous infusion of nitroprusside, dobutamine, milrinone, or other agent) including assessing hemodynamic measurements before, during, after and repeat pharmacologic agent administration, when performed |
| C9169 | Injection, nogapendekin alfa inbakicept-pmln, for intravesical use, 1 microgram |
| C9170 | Injection, tarlatamab-dlle, 1 mg |
| C9171 | Injection, pegulicianine, 1 mg |
| C9172 | Injection, fidanacogene elaparvovec-dzkt, per therapeutic dose |
| C9290 | Injection, bupivacaine liposome, 1 mg |
| C9769 | Cystourethroscopy, with insertion of temporary prostatic implant/stent with fixation/anchor and incisional struts |
| C9786 | Echocardiography image post processing for computer aided detection of heart failure with preserved ejection fraction, including interpretation and report |
| C9794 | Therapeutic radiology simulation-aided field setting; complex, including acquisition of pet and ct imaging data required for radiopharmaceutical-directed radiation therapy treatment planning (i.e., modeling) |
| C9795 | Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance and real-time positron emissions-based delivery adjustments to 1 or more lesions, entire course not to exceed 5 fractions |
| D2941 | Interim therapeutic restoration - primary dentition |
| D6095 | Repair implant abutment, by report |
| G0106 | Colorectal cancer screening; alternative to g0104, screening sigmoidoscopy, barium enema |
| G0120 | Colorectal cancer screening; alternative to g0105, screening colonoscopy, barium enema. |
| G0122 | Colorectal cancer screening; barium enema |
| G1001 | Clinical decision support mechanism evicore, as defined by the medicare appropriate use criteria program |
| G1002 | Clinical decision support mechanism medcurrent, as defined by the medicare appropriate use criteria program |
| G1003 | Clinical decision support mechanism medicalis, as defined by the medicare appropriate use criteria program |
| G1004 | Clinical decision support mechanism national decision support company, as defined by the medicare appropriate use criteria program |
| G1005 | Clinical decision support mechanism national imaging associates, as defined by the medicare appropriate use criteria program |
| G1006 | Clinical decision support mechanism test appropriate, as defined by the medicare appropriate use criteria program |
| G1007 | Clinical decision support mechanism aim specialty health, as defined by the medicare appropriate use criteria program |
| G1008 | Clinical decision support mechanism cranberry peak, as defined by the medicare appropriate use criteria program |
| G1010 | Clinical decision support mechanism stanson, as defined by the medicare appropriate use criteria program |
| G1011 | Clinical decision support mechanism, qualified tool not otherwise specified, as defined by the medicare appropriate use criteria program |
| G1012 | Clinical decision support mechanism agilemd, as defined by the medicare appropriate use criteria program |
| G1013 | Clinical decision support mechanism evidencecare imagingcare, as defined by the medicare appropriate use criteria program |
| G1014 | Clinical decision support mechanism inveniqa semantic answers in medicine, as defined by the medicare appropriate use criteria program |
| G1015 | Clinical decision support mechanism reliant medical group, as defined by the medicare appropriate use criteria program |
| G1016 | Clinical decision support mechanism speed of care, as defined by the medicare appropriate use criteria program |
| G1017 | Clinical decision support mechanism healthhelp, as defined by the medicare appropriate use criteria program |
| G1018 | Clinical decision support mechanism infinx, as defined by the medicare appropriate use criteria program |
| G1019 | Clinical decision support mechanism logicnets, as defined by the medicare appropriate use criteria program |
| G1020 | Clinical decision support mechanism curbside clinical augmented workflow, as defined by the medicare appropriate use criteria program |
| G1021 | Clinical decision support mechanism ehealthline clinical decision support mechanism, as defined by the medicare appropriate use criteria program |
| G1022 | Clinical decision support mechanism intermountain clinical decision support mechanism, as defined by the medicare appropriate use criteria program |
| G1023 | Clinical decision support mechanism persivia clinical decision support, as defined by the medicare appropriate use criteria program |
| G1024 | Clinical decision support mechanism radrite, as defined by the medicare appropriate use criteria program |
| G2012 | Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion |
| G2070 | Medication assisted treatment, buprenorphine (implant insertion); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a medicare-enrolled opioid treatment program) |
| G2071 | Medication assisted treatment, buprenorphine (implant removal); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a medicare-enrolled opioid treatment program) |
| G2072 | Medication assisted treatment, buprenorphine (implant insertion and removal); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a medicare-enrolled opioid treatment program) |
| G8482 | Influenza immunization administered or previously received |
| G8483 | Influenza immunization was not administered for reasons documented by clinician (e.g., patient allergy or other medical reasons, patient declined or other patient reasons, vaccine not available or other system reasons) |
| G8484 | Influenza immunization was not administered, reason not given |
| G8965 | Cardiac stress imaging test primarily performed on low chd risk patient for initial detection and risk assessment |
| G8966 | Cardiac stress imaging test performed on symptomatic or higher than low chd risk patient or for any reason other than initial detection and risk assessment |
| G9402 | Patient received follow-up within 30 days after discharge |
| G9403 | Clinician documented reason patient was not able to complete 30 day follow-up from acute inpatient setting discharge (e.g., patient death prior to follow-up visit, patient non-compliant for visit follow-up) |
| G9404 | Patient did not receive follow-up within 30 days after discharge |
| G9405 | Patient received follow-up within 7 days after discharge |
| G9406 | Clinician documented reason patient was not able to complete 7 day follow-up from acute inpatient setting discharge (i.e patient death prior to follow-up visit, patient non-compliance for visit follow-up) |
| G9407 | Patient did not receive follow-up within 7 days after discharge |
| G9458 | Patient documented as tobacco user and received tobacco cessation intervention (must include at least one of the following: advice given to quit smoking or tobacco use, counseling on the benefits of quitting smoking or tobacco use, assistance with or referral to external smoking or tobacco cessation support programs, or current enrollment in smoking or tobacco use cessation program) if identified as a tobacco user |
| G9459 | Currently a tobacco non-user |
| G9460 | Tobacco assessment or tobacco cessation intervention not performed, reason not given |
| G9707 | Patient received hospice services any time during the measurement period |
| G9751 | Patient died at any time during the 24-month measurement period |
| G9760 | Patients who use hospice services any time during the measurement period |
| G9892 | Documentation of patient reason(s) for not performing a dilated macular examination |
| G9893 | Dilated macular exam was not performed, reason not otherwise specified |
| G9919 | Screening performed and positive and provision of recommendations |
| G9920 | Screening performed and negative |
| G9921 | No screening performed, partial screening performed or positive screen without recommendations and reason is not given or otherwise specified |
| G9974 | Dilated macular exam performed, including documentation of the presence or absence of macular thickening or geographic atrophy or hemorrhage and the level of macular degeneration severity |
| G9975 | Documentation of medical reason(s) for not performing a dilated macular examination |
| G9990 | Patient did not receive any pneumococcal conjugate or polysaccharide vaccine on or after their 19th birthday and before the end of the measurement period |
| G9991 | Patient received any pneumococcal conjugate or polysaccharide vaccine on or after their 19th birthday and before the end of the measurement period |
| J0135 | Injection, adalimumab, 20 mg |
| J0570 | Buprenorphine implant, 74.2 mg |
| J2796 | Injection, romiplostim, 10 micrograms |
| J2806 | Injection, sincalide (maia), not therapeutically equivalent to j2805, 5 micrograms |
| J9058 | Injection, bendamustine hydrochloride (apotex), 1 mg |
| J9059 | Injection, bendamustine hydrochloride (baxter), 1 mg |
| J9259 | Injection, paclitaxel protein-bound particles (american regent), not therapeutically equivalent to j9264, 1 mg |
| M0003 | Optimal care for patients with episodic neurological conditions mips value pathways |
| M1154 | Hospice services provided to patient any time during the measurement period |
| M1155 | Patient had anaphylaxis due to the pneumococcal vaccine any time during or before the measurement period |
| M1219 | Anaphylaxis due to the vaccine on or before the date of the encounter |
| M1264 | Patients age 75 or older on their initiation of dialysis date |
| Q0516 | Pharmacy supplying fee for hiv pre-exposure prophylaxis fda approved prescription oral drug, per 30-days |
| Q0517 | Pharmacy supplying fee for hiv pre-exposure prophylaxis fda approved prescription oral drug, per 60-days |
| Q0518 | Pharmacy supplying fee for hiv pre-exposure prophylaxis fda approved prescription oral drug, per 90-days |
| Q0519 | Pharmacy supplying fee for hiv pre-exposure prophylaxis fda approved prescription injectable drug, per 30-days |
| Q0520 | Pharmacy supplying fee for hiv pre-exposure prophylaxis fda approved prescription injectable drug, per 60-days |
| Q5131 | Injection, adalimumab-aacf (idacio), biosimilar, 20 mg |
| Q5132 | Injection, adalimumab-afzb (abrilada), biosimilar, 10 mg |
Source
Transmittal 12791, CR 13688 dated August 15, 2024
Last Updated Dec 12 , 2024
