Highmark Medical Policy Bulletin

Section: Visits
Number: V-31
Topic: Medical Visits & Associated Services
Effective Date: March 12, 2001
Issued Date: March 12, 2001
Date Last Reviewed:

General Policy Guidelines

The services on the Text Attachment are considered an integral part of a doctor's medical or surgical care. They are not eligible as distinct and separate services when performed with medical or surgical care.

Procedure Codes

158521725020500206902110029130
291312920029220292402926029280
295202953029540295502958029590
315023150532005354003600036400
364053640636410437524376046600
506885423554450571505716058350
654306921087168871699106092100
922259222692250922609250492511
946409476094761947629583195832
958339583495851958529587596902
978029780397804990509905299054
990569907099172991739935499355
993569935799358993599937499375
99377993789937999380G0179G0180
G0181G0182S0820S9474  

Traditional (UCR/Fee Schedule) Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Ophthalmoscopy (92225, 92226, 92250, and 92260) may be paid in addition to medical care reported on the same day.

Also refer to General Policy Guidelines

Comprehensive/Wraparound/PPO Guidelines

Refer to General Policy Guidelines

Managed Care (HMO/POS) Guidelines

Refer to General Policy Guidelines

Publications

References

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Table Attachment


Text Attachment

Services

  1. Administration of IV Innovar
  2. Amsler Grid Test
  3. Analysis of data from Swan-Ganz Catheterization
  4. Anoscopy without biopsy (46600)
  5. Angioscopy (non-coronary vessels or grafts) during therapeutic intervention (35400)
  6. Application of external fixation system (20690)
  7. Application of halo type appliance for maxillofacial fixation, includes removal (21100)
  8. Application of splint (29130-29131)
  9. Application of traction, suspension, or corrective appliance (non-fracture care)
  10. Blood pressure check
  11. Blue field entoptoscopic exam
  12. Breast exam
  13. Brightness Acuity Test
  14. Canalith repositioning procedure (a.k.a., Epley maneuvers, Otolith repositioning)
  15. Care plan oversight services (99374-99380)
  16. Catheter site inspection by physician
  17. Changing of tubes
    1. connecting tube
    2. gastrostomy tube or button(43760)
    3. tracheostomy tube
    4. tracheotomy tube (31502)
    5. ureterostomy tube (50688)
  18. Chemical cauterization of granulation tissue (17250)
  19. Chemical pleurodesis (e.g., for recurrent or persistent pneumothorax) (32005)
  20. Corneal scrapings (65430)
  21. Corneal topography/corneal-assisted photokeratoscopy (S0820)
  22. Dressing change (for other than burns) under anesthesia (other than local) (15852)
  23. Ear/pulse oximetry (94760-94762)
  24. Enterostomal therapy (S9474)
  25. Eye tonometry (92100)
  26. Foreskin manipulation including lysis of preputial adhesions and stretching (54450)
  27. Gastric saline load test (91060)
  28. Grenz ray therapy
  29. Hydrotubation of oviduct (tubal lavage), including materials (58350)
  30. Injection of corpora cavernosa with pharmacologic agent(s), e.g., papaverine, phentolamine, etc. (54235)
  31. Injection of sinus tract (therapeutic) (20500)
  32. Insertion of pessary (57160)
  33. Irrigation and/or application of medicament for treatment of bacterial, parasitic, or fungoid disease (57150)
  34. IV infusion therapy, administered by physician or under direct supervision of physician
  35. IV therapy for severe or intractable allergic disease in physician's office or institution with theophyllines, corticosteroids, antihistamines (excludes cost of the drug)
  36. Laryngoscopy, indirect/mirror, without biopsy (31505)
  37. Laser interferometry or retinometry
  38. Macroscopic examination of arthropod or parasite (87168, 87169)
  39. Magnified penile surface scanning (penoscopy)
  40. Manual, gross visual fields
  41. Medical nutrition therapy (97802-97804)
  42. Microscopic examination of hairs plucked or clipped by the examiner (excluding hair collected by the patient) to determine telogen and anagen counts, or structural hair shaft abnormality (96902)
  43. Miller-Nadler Glare Test
  44. Muscle testing (95831-95834, 95851-95852, 95875)
  45. Naso- or oro-gastric tube placement, necessitating physician's skill (43752)
  46. Nasopharyngolaryngoscopy (indirect)
  47. Nasopharyngoscopy (92511)
  48. Nonpressurized inhalation treatment for acute airway obstruction (94640)
  49. Ophthalmodynamometry (92260)
  50. Ophthalmoscopy (92225, 92226)
  51. Otoscopy (no removal of foreign body)
  52. Phototherapy (for neonatal jaundice)
  53. Physician certification services for Medicare-covered services provided by a participating home health agency (patient not present)(G0180)
  54. Physician recertification services for Medicare-covered services provided by a participating home health agency (patient not present)(G0179)
  55. Physician supervision of a patient receiving Medicare-approved hospice (patient not present) requiring complex and multidisciplinary care modalities (G0182)
  56. Physician supervision of a patient receiving Medicare-covered services provided by a participating home health agency (patient not present) requiring complex and multidisciplinary care modalities (G0181)
  57. Placement of nasogastric feeding tube
  58. Potential acuity testing (visual)
    1. PAM (potential acuity meter)
    2. Guyton - Minkowski test
    3. visometer or retinometer
    4. macular integrity or electro-laser test
  59. Prolonged services (99354-99359)
  60. Prostatic massage
  61. Removal of cerumen (69210)
  62. Removal non-contraceptive pellets or capsules (FEP and Special Contracts
    Only-Noncovered under Standard Contracts)
  63. Rhinoscopy (no removal of foreign body)
  64. Schirmer test
  65. Screening test, visual acuity (99173)
  66. Slit lamp test (biomicroscopy, binocular microscopy and fluorescein staining) (92504)
  67. Special Services (99050-99056)
  68. Starting of an IV (See MPB G-16 for information on starting of an IV under the chemotherapy benefit) (36000)
  69. Stat charges for laboratory services
  70. Strapping of joint, including flexible, gel, and soft casts (29200-29280, 29520-29590)
  71. Supplies and materials (except spectacles), provided by the physician over and above those usually included with the office visit or other services rendered (99070)
  72. Telemetry
  73. Tuning fork test
  74. Venipuncture (36400-36410)
  75. Visual function screening, automated or semiautomated (99172)

Procedure Code Attachment


Glossary

TermDescription






Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.